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Espay AJ, Kepp KP, Herrup K. Lecanemab and Donanemab as Therapies for Alzheimer's Disease: An Illustrated Perspective on the Data. eNeuro 2024; 11:ENEURO.0319-23.2024. [PMID: 38951040 PMCID: PMC11218032 DOI: 10.1523/eneuro.0319-23.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 07/03/2024] Open
Affiliation(s)
- Alberto J Espay
- Department of Neurology, James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, Ohio 45219
| | - Kasper P Kepp
- Section of Biophysical and Biomedicinal Chemistry, Department of Chemistry, Technical University of Denmark, Kongens Lyngby 2800, Denmark
| | - Karl Herrup
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, Pennsylvania 15261
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Mestre TA, Stebbins GT, Stephenson D, Dexter D, Lee KK, Xiao Y, Dam T, Kopil CM, Simuni T. Patient-centered development of clinical outcome assessments in early Parkinson disease: key priorities and advances. NPJ Parkinsons Dis 2024; 10:101. [PMID: 38744872 PMCID: PMC11094181 DOI: 10.1038/s41531-024-00716-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 04/25/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
- Tiago A Mestre
- Ottawa Hospital Research Institute; University of Ottawa Brain and Mind Research Institute; Division of Neurology, Department of Medicine, University of Ottawa, The Ottawa Hospital Ottawa, Ottawa, ON, Canada.
| | - Glenn T Stebbins
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | | | | | | | - Yuge Xiao
- The Michael J. Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Tien Dam
- Neumora Therapeutics, Cambridge, MA, USA
| | - Catherine M Kopil
- The Michael J. Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Tanya Simuni
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Muir RT, Hill MD, Black SE, Smith EE. Minimal clinically important difference in Alzheimer's disease: Rapid review. Alzheimers Dement 2024; 20:3352-3363. [PMID: 38561021 PMCID: PMC11095473 DOI: 10.1002/alz.13770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION We conducted a rapid systematic review of minimal clinically important differences (MCIDs) for Alzheimer's disease (AD) trial endpoints. METHODS Two reviewers searched EMBASE, MEDLINE, and PubMed from inception to June 4, 2023. RESULTS Ten articles were retrieved. For mild cognitive impairment (MCI), a change of +2 to +3 points on the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), +1 points on the Clinical Dementia Rating scale sum of boxes (CDR-SB), -5 points on the integrated Alzheimer's Disease Rating Scale (iADRS), or -1 to -2 points on the Mini-Mental State Examination (MMSE) was considered meaningful. For patients with mild AD, a change of +3 on the ADAS-Cog, +2 points on CDR-SB, -9 points on the iADRS, or -2 points on the MMSE was considered meaningful. For patients with moderate to severe AD, a change of +2 points on the CDR-SB or a change of -1.4 to -3 points on the MMSE was considered meaningful. CONCLUSION This review identified previously published MCIDs for AD trial endpoints. Input from patients and caregivers will be needed to derive more meaningful endpoints and thresholds. HIGHLIGHTS This systematic rapid review identified thresholds for minimal clinically important differences (MCIDs) for recently used Alzheimer's disease (AD) trial endpoints: Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), Clinical Dementia Rating scale sum of boxes (CDR-SB), integrated Alzheimer's Disease Rating Scale (iADRS), Mini-Mental State Examination (MMSE). MCIDs were higher for more severe stages of AD. Average treatment effects in recent trials of anti-amyloid disease modifying monoclonal antibodies are lower than previously published MCIDs. In future trials of disease modifying treatments for AD, the proportion of participants in each treatment group that experienced a clinically meaningful decline could be reported. More work is needed to incorporate the values and preferences of patients and care partners in deriving MCIDs.
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Affiliation(s)
- Ryan T. Muir
- Department of Clinical Neurosciences and Department of Community Health SciencesCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Michael D. Hill
- Department of Clinical Neurosciences and Department of Community Health SciencesCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Sandra E. Black
- Division of NeurologyDepartment of MedicineSunnybrook Health Sciences CentreTorontoOntarioCanada
- L.C Campbell Cognitive Neurology Research UnitDr Sandra Black Centre for Brain Resilience and Recovery, and Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
| | - Eric E. Smith
- Department of Clinical Neurosciences and Department of Community Health SciencesCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
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Klein EG, Schroeder K, Wessels AM, Phipps A, Japha M, Schilling T, Zimmer JA. How donanemab data address the coverage with evidence development questions. Alzheimers Dement 2024; 20:3127-3140. [PMID: 38323738 PMCID: PMC11032520 DOI: 10.1002/alz.13700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 02/08/2024]
Abstract
The Centers for Medicare & Medicaid Services (CMS) established a class-based National Coverage Determination (NCD) for monoclonal antibodies directed against amyloid for Alzheimer's disease (AD) with patient access through Coverage with Evidence Development (CED) based on three questions. This review, focused on donanemab, answers each of these CED questions with quality evidence. TRAILBLAZER-ALZ registration trials are presented with supporting literature and real-world data to answer CED questions for donanemab. TRAILBLAZER-ALZ registration trials demonstrated that donanemab significantly slowed cognitive and functional decline in amyloid-positive early symptomatic AD participants, and lowered their risk of disease progression while key safety risks occurred primarily within the first 6 months and then declined. Donanemab meaningfully improved health outcomes with a manageable safety profile in an early symptomatic AD population, representative of Medicare populations across diverse practice settings. The donanemab data provide the necessary level of evidence for CMS to open a reconsideration of their NCD. HIGHLIGHTS: Donanemab meaningfully improved outcomes in trial participants with early symptomatic Alzheimer's disease. Comorbidities in trial participants were consistent with the Medicare population. Co-medications in trial participants were consistent with the Medicare population. Risks associated with treatment tended to occur in the first 6 months. Risks of amyloid-related imaging abnormalities were managed with careful observation and magnetic resonance imaging monitoring.
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Affiliation(s)
- Eric G. Klein
- Global Medical Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Krista Schroeder
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Alette M. Wessels
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Adam Phipps
- Lilly Value and Access, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Maureen Japha
- Corporate Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Traci Schilling
- Global Medical Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Jennifer A. Zimmer
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
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Sarkisian CA, Romanov A, Mafi JN. Talking With Patients About the New Anti-amyloid Alzheimer Disease Medications. Ann Intern Med 2024; 177:246-248. [PMID: 38252943 DOI: 10.7326/m23-3377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Affiliation(s)
- Catherine A Sarkisian
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, and Geriatrics Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California (C.A.S.)
| | - Artem Romanov
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California (A.R.)
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, and RAND Corporation, Santa Monica, California (J.N.M.)
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Evans CD, Sparks J, Andersen SW, Brooks DA, Hauck PM, Mintun MA, Sims JR. APOE ε4's impact on response to amyloid therapies in early symptomatic Alzheimer's disease: Analyses from multiple clinical trials. Alzheimers Dement 2023; 19:5407-5417. [PMID: 37204338 DOI: 10.1002/alz.13128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Apolipoprotein E (APOE) ε4 may interact with response to amyloid-targeting therapies. METHODS Aggregate data from trials enrolling participants with amyloid-positive, early symptomatic Alzheimer's disease (AD) were analyzed for disease progression. RESULTS Pooled analysis of potentially efficacious antibodies lecanemab, aducanumab, solanezumab, and donanemab shows slightly better efficacy in APOE ε4 carriers than in non-carriers. Carrier and non-carrier mean (95% confidence interval) differences from placebo using Clinical Dementia Rating Scale-Sum of Boxes (CDR-SB) were -0.30 (-0.478, -0.106) and -0.20 (-0.435, 0.042) and AD Assessment Scale-Cognitive subscale (ADAS-Cog) values were -1.01 (-1.577, -0.456) and -0.80 (-1.627, 0.018), respectively. Decline in the APOE ε4 non-carrier placebo group was equal to or greater than that in carriers across multiple scales. Probability of study success increases as the representation of the carrier population increases. DISCUSSION We hypothesize that APOE ε4 carriers have same or better response than non-carriers to amyloid-targeting therapies and similar or less disease progression with placebo in amyloid-positive trials. HIGHLIGHTS Amyloid-targeting therapies had slightly greater efficacy in apolipoprotein E (APOE) ε4 carriers. Clinical decline is the same/slightly faster in amyloid-positive APOE ε4 non-carriers. Prevalence of non-carriers in trial populations could impact outcomes.
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Affiliation(s)
| | | | | | | | | | - Mark A Mintun
- Eli Lilly and Company, Indianapolis, Indiana, USA
- Avid Radiopharmaceuticals, a wholly owned subsidiary of Eli Lilly and Company, Philadelphia, Pennsylvania, USA
| | - John R Sims
- Eli Lilly and Company, Indianapolis, Indiana, USA
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Sims JR, Zimmer JA, Evans CD, Lu M, Ardayfio P, Sparks J, Wessels AM, Shcherbinin S, Wang H, Monkul Nery ES, Collins EC, Solomon P, Salloway S, Apostolova LG, Hansson O, Ritchie C, Brooks DA, Mintun M, Skovronsky DM. Donanemab in Early Symptomatic Alzheimer Disease: The TRAILBLAZER-ALZ 2 Randomized Clinical Trial. JAMA 2023; 330:512-527. [PMID: 37459141 PMCID: PMC10352931 DOI: 10.1001/jama.2023.13239] [Citation(s) in RCA: 362] [Impact Index Per Article: 362.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
Importance There are limited efficacious treatments for Alzheimer disease. Objective To assess efficacy and adverse events of donanemab, an antibody designed to clear brain amyloid plaque. Design, Setting, and Participants Multicenter (277 medical research centers/hospitals in 8 countries), randomized, double-blind, placebo-controlled, 18-month phase 3 trial that enrolled 1736 participants with early symptomatic Alzheimer disease (mild cognitive impairment/mild dementia) with amyloid and low/medium or high tau pathology based on positron emission tomography imaging from June 2020 to November 2021 (last patient visit for primary outcome in April 2023). Interventions Participants were randomized in a 1:1 ratio to receive donanemab (n = 860) or placebo (n = 876) intravenously every 4 weeks for 72 weeks. Participants in the donanemab group were switched to receive placebo in a blinded manner if dose completion criteria were met. Main Outcomes and Measures The primary outcome was change in integrated Alzheimer Disease Rating Scale (iADRS) score from baseline to 76 weeks (range, 0-144; lower scores indicate greater impairment). There were 24 gated outcomes (primary, secondary, and exploratory), including the secondary outcome of change in the sum of boxes of the Clinical Dementia Rating Scale (CDR-SB) score (range, 0-18; higher scores indicate greater impairment). Statistical testing allocated α of .04 to testing low/medium tau population outcomes, with the remainder (.01) for combined population outcomes. Results Among 1736 randomized participants (mean age, 73.0 years; 996 [57.4%] women; 1182 [68.1%] with low/medium tau pathology and 552 [31.8%] with high tau pathology), 1320 (76%) completed the trial. Of the 24 gated outcomes, 23 were statistically significant. The least-squares mean (LSM) change in iADRS score at 76 weeks was -6.02 (95% CI, -7.01 to -5.03) in the donanemab group and -9.27 (95% CI, -10.23 to -8.31) in the placebo group (difference, 3.25 [95% CI, 1.88-4.62]; P < .001) in the low/medium tau population and -10.2 (95% CI, -11.22 to -9.16) with donanemab and -13.1 (95% CI, -14.10 to -12.13) with placebo (difference, 2.92 [95% CI, 1.51-4.33]; P < .001) in the combined population. LSM change in CDR-SB score at 76 weeks was 1.20 (95% CI, 1.00-1.41) with donanemab and 1.88 (95% CI, 1.68-2.08) with placebo (difference, -0.67 [95% CI, -0.95 to -0.40]; P < .001) in the low/medium tau population and 1.72 (95% CI, 1.53-1.91) with donanemab and 2.42 (95% CI, 2.24-2.60) with placebo (difference, -0.7 [95% CI, -0.95 to -0.45]; P < .001) in the combined population. Amyloid-related imaging abnormalities of edema or effusion occurred in 205 participants (24.0%; 52 symptomatic) in the donanemab group and 18 (2.1%; 0 symptomatic during study) in the placebo group and infusion-related reactions occurred in 74 participants (8.7%) with donanemab and 4 (0.5%) with placebo. Three deaths in the donanemab group and 1 in the placebo group were considered treatment related. Conclusions and Relevance Among participants with early symptomatic Alzheimer disease and amyloid and tau pathology, donanemab significantly slowed clinical progression at 76 weeks in those with low/medium tau and in the combined low/medium and high tau pathology population. Trial Registration ClinicalTrials.gov Identifier: NCT04437511.
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Affiliation(s)
| | | | | | - Ming Lu
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | | | | | - Hong Wang
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | - Paul Solomon
- Boston Center for Memory and Boston University Alzheimer’s Disease Center, Boston, Massachusetts
| | - Stephen Salloway
- Department of Neurology and Department of Psychiatry, Alpert Medical School of Brown University, Providence, Rhode Island
- Butler Hospital, Providence, Rhode Island
| | - Liana G. Apostolova
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Oskar Hansson
- Clinical Memory Research Unit, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden; Memory Clinic, Skåne University Hospital, Lund, Sweden
| | | | | | - Mark Mintun
- Eli Lilly and Company, Indianapolis, Indiana
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Wessels AM, Dennehy EB, Dowsett SA, Dickson SP, Hendrix SB. Meaningful Clinical Changes in Alzheimer Disease Measured With the iADRS and Illustrated Using the Donanemab TRAILBLAZER-ALZ Study Findings. Neurol Clin Pract 2023; 13:e200127. [PMID: 36891463 PMCID: PMC9987204 DOI: 10.1212/cpj.0000000000200127] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/09/2022] [Indexed: 02/18/2023]
Abstract
Purpose of Review To provide relevant background of the Integrated Alzheimer's Disease Rating Scale (iADRS), with examples, to assist the reader with the interpretation of iADRS findings from the TRAILBLAZER-ALZ study. Recent Findings The iADRS is an integrated measure of global Alzheimer disease (AD) severity for use in the clinical trial environment. It provides a single score that captures commonalities across cognitive and functional ability domains, reflecting disease-related impairment, while minimizing noise not related to disease progression that may exist within each domain. In AD, disease-modifying therapies (DMTs) are expected to slow the rate of clinical decline, changing the trajectory of disease progression. The overall percent slowing of disease progression with treatment is a more informative outcome of effect than absolute point differences between treatment and placebo groups at any given time point because the latter is influenced by treatment period and disease severity. The TRAILBLAZER-ALZ trial was a phase 2 study designed to evaluate the safety and efficacy of donanemab in participants with early symptomatic AD; the primary outcome measure was the change from baseline to 76 weeks on the iADRS. In the TRAILBLAZER-ALZ study, donanemab slowed disease progression by 32% at 18 months (p = 0.04 vs placebo), demonstrating clinical efficacy. At the patient level, one can assess whether the DMT effect is clinically meaningful by estimating the threshold of change consistent with clinically meaningful worsening; based on the TRAILBLAZER-ALZ findings, treatment with donanemab would delay reaching this threshold by approximately 6 months. Summary The iADRS is capable of accurately describing clinical changes associated with disease progression and detecting treatment effects and is an effective assessment tool for use in clinical trials of individuals with early symptomatic AD.
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Affiliation(s)
- Alette M Wessels
- Eli Lilly and Company (AMW, EBD, SAD), Indianapolis, IN; Department of Psychological Sciences (EBD), Purdue University, West Lafayette, IN; and Pentara Corporation (SPD, SBH), Millcreek, UT
| | - Ellen B Dennehy
- Eli Lilly and Company (AMW, EBD, SAD), Indianapolis, IN; Department of Psychological Sciences (EBD), Purdue University, West Lafayette, IN; and Pentara Corporation (SPD, SBH), Millcreek, UT
| | - Sherie A Dowsett
- Eli Lilly and Company (AMW, EBD, SAD), Indianapolis, IN; Department of Psychological Sciences (EBD), Purdue University, West Lafayette, IN; and Pentara Corporation (SPD, SBH), Millcreek, UT
| | - Samuel P Dickson
- Eli Lilly and Company (AMW, EBD, SAD), Indianapolis, IN; Department of Psychological Sciences (EBD), Purdue University, West Lafayette, IN; and Pentara Corporation (SPD, SBH), Millcreek, UT
| | - Suzanne B Hendrix
- Eli Lilly and Company (AMW, EBD, SAD), Indianapolis, IN; Department of Psychological Sciences (EBD), Purdue University, West Lafayette, IN; and Pentara Corporation (SPD, SBH), Millcreek, UT
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Gueorguieva I, Chua L, Willis BA, Sims JR, Wessels AM. Disease progression model using the integrated Alzheimer's Disease Rating Scale. Alzheimers Dement 2022. [DOI: 10.1002/alz.12876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/27/2022] [Accepted: 10/21/2022] [Indexed: 12/03/2022]
Affiliation(s)
| | - Laiyi Chua
- Eli Lilly and Company Indianapolis Indiana USA
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