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Ketabforoush A, Faghihi F, Azedi F, Ariaei A, Habibi MA, Khalili M, Ashtiani BH, Joghataei MT, Arnold WD. Sodium Phenylbutyrate and Tauroursodeoxycholic Acid: A Story of Hope Turned to Disappointment in Amyotrophic Lateral Sclerosis Treatment. Clin Drug Investig 2024; 44:495-512. [PMID: 38909349 DOI: 10.1007/s40261-024-01371-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 06/24/2024]
Abstract
The absence of a definitive cure for amyotrophic lateral sclerosis (ALS) emphasizes the crucial need to explore new and improved treatment approaches for this fatal, progressive, and disabling neurodegenerative disorder. As at the end of 2023, five treatments - riluzole, edaravone, dextromethorphan hydrobromide + quinidine sulfate (DHQ), tofersen, and sodium phenylbutyrate-tauroursodeoxycholic acid (PB-TUDCA) - were FDA approved for the treatment of patients with ALS. Among them PB-TUDCA has been shown to impact DNA processing impairments, mitochondria dysfunction, endoplasmic reticulum stress, oxidative stress, and pathologic folded protein agglomeration defects, which have been associated with ALS pathophysiology. The Phase 2 CENTAUR trial demonstrated significant impact of PB-TUDCA on the ALS Functional Rating Scale-Revised (ALSFRS-R) risk of death, hospitalization, and the need for tracheostomy or permanent assisted ventilation in patients with ALS based on post hoc analyses. More recently, contrasting with the CENTAUR trial results, results from the Phase 3 PHOENIX trial (NCT05021536) showed no change in ALSFRS-R total score at 48 weeks. Consequently, the sponsor company initiated the process with the US FDA and Health Canada to voluntarily withdraw the marketing authorizations for PB-TUDCA. In the present article, we review ALS pathophysiology, with a focus on PB-TUDCA's proposed mechanisms of action and recent clinical trial results and discuss the implications of conflicting trial data for ALS and other neurological disorders.
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Affiliation(s)
- Arsh Ketabforoush
- NextGen Precision Health, University of Missouri, 1030 Hitt St., Columbia, MO, 65211, USA
- Department of Physical Medicine and Rehabilitation, University of Missouri, Columbia, MO, USA
| | - Faezeh Faghihi
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fereshteh Azedi
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Armin Ariaei
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Amin Habibi
- Clinical Research Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
| | - Maryam Khalili
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Haghi Ashtiani
- Department of Neurology, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghi Joghataei
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - W David Arnold
- NextGen Precision Health, University of Missouri, 1030 Hitt St., Columbia, MO, 65211, USA.
- Department of Physical Medicine and Rehabilitation, University of Missouri, Columbia, MO, USA.
- Department of Neurology, University of Missouri, Columbia, MO, USA.
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA.
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Malaspina A. Use of biomarkers in clinical trials and future developments that will help identify novel biomarkers. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:171-207. [PMID: 38802175 DOI: 10.1016/bs.irn.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Engineering new solutions for therapeutic benefit in Amyotrophic Lateral Sclerosis (ALS) has proved a difficult task to accomplish. This is largely the reflection of complexities at multiple levels, that require solutions to improve cost-effectiveness and outcomes. The main obstacle related to the condition's clinical heterogeneity, chiefly the broad difference in survival observed among ALS patients, imposes large populations studies and long follow-up to evaluate any efficacy. The emerging solution is composite clinical and biological parameters enabling prognostic stratification into homogeneous phenotypes for more affordable studies. From a therapeutic development perspective, the choice of a medicinal product requires the availability of treatment-specific biomarkers of target engagement to identify off-target effects based on the compound's putative modality of action. More importantly, there are no established biomarkers of treatment response that can complement clinical outcome measures and support futility and end of treatment analyses of efficacy. Ultimately the onus rests on the development of biomarkers encompassing the unmet needs of clinical trial design, from inclusion to efficacy. These readouts of the pathological process may be used in combination with clinical and paraclinical outcome measured, significantly reducing the time and financial burden of clinical studies. Progress towards a biomarker-driven clinical trial design in ALS has been possible thanks to the accurate detection of neurofilaments and of other immunological mediators in biological fluids with the disease progression, a step change enabling the testing of novel therapeutic agents in a new clinical trial setting. However, further progress remains to be made to find treatment specific target engagement biomarkers along with readouts of treatment response that can be reliably applied to all emerging therapies and clinical studies. Here we will cover the basic notions of biomarker development in ALS clinical trials, the most crucial unanswered questions and the unmet needs in the ALS biomarkers space.
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Affiliation(s)
- Andrea Malaspina
- Professor of Neurology, Queen Square MND Centre, Instute of Neurology, London, United Kingdom.
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Lee A, Henderson R, Aylward J, McCombe P. Gut Symptoms, Gut Dysbiosis and Gut-Derived Toxins in ALS. Int J Mol Sci 2024; 25:1871. [PMID: 38339149 PMCID: PMC10856138 DOI: 10.3390/ijms25031871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Many pathogenetic mechanisms have been proposed for amyotrophic lateral sclerosis (ALS). Recently, there have been emerging suggestions of a possible role for the gut microbiota. Gut microbiota have a range of functions and could influence ALS by several mechanisms. Here, we review the possible role of gut-derived neurotoxins/excitotoxins. We review the evidence of gut symptoms and gut dysbiosis in ALS. We then examine a possible role for gut-derived toxins by reviewing the evidence that these molecules are toxic to the central nervous system, evidence of their association with ALS, the existence of biochemical pathways by which these molecules could be produced by the gut microbiota and existence of mechanisms of transport from the gut to the blood and brain. We then present evidence that there are increased levels of these toxins in the blood of some ALS patients. We review the effects of therapies that attempt to alter the gut microbiota or ameliorate the biochemical effects of gut toxins. It is possible that gut dysbiosis contributes to elevated levels of toxins and that these could potentially contribute to ALS pathogenesis, but more work is required.
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Affiliation(s)
- Aven Lee
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (R.H.); (P.M.)
| | - Robert Henderson
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (R.H.); (P.M.)
- Department of Neurology, Royal Brisbane & Women’s Hospital, Brisbane, QLD 4029, Australia
- Wesley Research Institute, The Wesley Hospital, Auchenflower, QLD 4066, Australia;
| | - James Aylward
- Wesley Research Institute, The Wesley Hospital, Auchenflower, QLD 4066, Australia;
| | - Pamela McCombe
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (R.H.); (P.M.)
- Department of Neurology, Royal Brisbane & Women’s Hospital, Brisbane, QLD 4029, Australia
- Wesley Research Institute, The Wesley Hospital, Auchenflower, QLD 4066, Australia;
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