1
|
Moyer H, Mellett R, Vigneault K, McKeown M, Karlawish J, Augustine E, Schneider L, Kimmelman J. Prevalence and Impact of Bypassing or Overriding Phase 2 Trials in Neurologic Drug Development. Neurology 2024; 103:e209533. [PMID: 38833654 DOI: 10.1212/wnl.0000000000209533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pivotal trials for neurologic drugs in clinical development are often initiated without a phase 2 trial ("bypass") or despite a negative phase 2 efficacy result ("override"). Such practices may degrade the risk/benefit ratio of phase 3 trials. The aim of this study is to estimate the proportion of phase 3 trials for 10 neurologic diseases started without a positive phase 2 trial, to identify factors associated with this practice, and to investigate any association with unfavorable phase 3 trial outcomes. METHODS We searched ClinicalTrials.gov for phase 3 trials completed during 2011-2021, with at least 1 research site in the United States, Canada, the European Union, the United Kingdom, or Australia, and investigating drugs or biologics for treatment of 10 neurologic conditions. Our primary objective was to assess the prevalence of phase 2 bypass/override by searching for preceding phase 2 trials. We used Fisher exact tests to determine whether phase 3 trial characteristics and trial results were associated with phase 2 bypass/override. RESULTS Of the 1,188 phase 3 trials captured in our search, 113 met eligibility for inclusion. Of these, 46% were not preceded by a phase 2 trial that was positive on an efficacy endpoint (31% bypassed and 15% overrode phase 2 trial). Phase 2 bypass/override was not associated with industry funding (77% vs 89%, 95% CI 0.75-7.55, p = 0.13) or testing already approved interventions (23% vs 15%, 95% CI 0.60-5.14, p = 0.33). Overall, phase 3 trials based on phase 2 bypassed/override were statistically significantly less likely to be positive on their primary outcome (31% vs 57%, respectively, 95% CI 1.21-6.92, p = 0.01). This effect disappeared when indications characterized by nearly universal positive or negative results were excluded. Trials that bypassed/overrode phase 2 trials were not statistically significantly more likely to be terminated early because of safety or futility (29% vs 15%, respectively, 95% CI 0.15-1.18, p = 0.11) and did not show increased risk of adverse events in experimental arms (RR = 1.46, 95% CI 1.19-1.79, vs RR = 1.36, 95% CI 1.10-1.69, respectively, p = 0.65). DISCUSSION Almost half of the neurologic disease phase 3 trials were initiated without the support of a positive phase 2 trial. Although our analysis does not establish harm with bypass/override, its prevalence and the scientific rationale for phase 2 trial testing favor development of criteria defining when phase 2 bypass/override is justified.
Collapse
Affiliation(s)
- Hannah Moyer
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Robyn Mellett
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Karine Vigneault
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Maya McKeown
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Jason Karlawish
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Erika Augustine
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Lon Schneider
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Jonathan Kimmelman
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| |
Collapse
|
2
|
Benatar M, Hansen T, Rom D, Geist MA, Blaettler T, Camu W, Kuzma-Kozakiewicz M, van den Berg LH, Morales RJ, Chio A, Andersen PM, Pradat PF, Lange D, Van Damme P, Mora G, Grudniak M, Elliott M, Petri S, Olney N, Ladha S, Goyal NA, Meyer T, Hanna MG, Quinn C, Genge A, Zinman L, Jabari D, Shoesmith C, Ludolph AC, Neuwirth C, Nations S, Shefner JM, Turner MR, Wuu J, Bennett R, Dang H, Sundgreen C. Safety and efficacy of arimoclomol in patients with early amyotrophic lateral sclerosis (ORARIALS-01): a randomised, double-blind, placebo-controlled, multicentre, phase 3 trial. Lancet Neurol 2024; 23:687-699. [PMID: 38782015 DOI: 10.1016/s1474-4422(24)00134-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Amyotrophic lateral sclerosis is a progressive neurodegenerative disorder leading to muscle weakness and respiratory failure. Arimoclomol, a heat-shock protein-70 (HSP70) co-inducer, is neuroprotective in animal models of amyotrophic lateral sclerosis, with multiple mechanisms of action, including clearance of protein aggregates, a pathological hallmark of sporadic and familial amyotrophic lateral sclerosis. We aimed to evaluate the safety and efficacy of arimoclomol in patients with amyotrophic lateral sclerosis. METHODS ORARIALS-01 was a multinational, randomised, double-blind, placebo-controlled, parallel-group trial done at 29 centres in 12 countries in Europe and North America. Patients were eligible if they were aged 18 years or older and met El Escorial criteria for clinically possible, probable, probable laboratory-supported, definite, or familial amyotrophic lateral sclerosis; had an ALS Functional Rating Scale-Revised score of 35 or more; and had slow vital capacity at 70% or more of the value predicted on the basis of the participant's age, height, and sex. Patients were randomly assigned (2:1) in blocks of 6, stratified by use of a stable dose of riluzole or no riluzole use, to receive oral arimoclomol citrate 1200 mg/day (400 mg three times per day) or placebo. The Randomisation sequence was computer generated centrally. Investigators, study personnel, and study participants were masked to treatment allocation. The primary outcome was the Combined Assessment of Function and Survival (CAFS) rank score over 76 weeks of treatment. The primary outcome and safety were analysed in the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT03491462, and is completed. FINDINGS Between July 31, 2018, and July 17, 2019, 287 patients were screened, 245 of whom were enrolled in the trial and randomly assigned. The modified intention-to-treat population comprised 239 patients (160 in the arimoclomol group and 79 in the placebo group): 151 (63%) were male and 88 (37%) were female; mean age was 57·6 years (SD 10·9). CAFS score over 76 weeks did not differ between groups (mean 0·51 [SD 0·29] in the arimoclomol group vs 0·49 [0·28] in the placebo group; p=0·62). Cliff's delta comparing the two groups was 0·039 (95% CI -0·116 to 0·194). Proportions of participants who died were similar between the treatment groups: 29 (18%) of 160 patients in the arimoclomol group and 18 (23%) of 79 patients in the placebo group. Most deaths were due to disease progression. The most common adverse events were gastrointestinal. Adverse events were more often deemed treatment-related in the arimoclomol group (104 [65%]) than in the placebo group (41 [52%]) and more often led to treatment discontinuation in the arimoclomol group (26 [16%]) than in the placebo group (four [5%]). INTERPRETATION Arimoclomol did not improve efficacy outcomes compared with placebo. Although available biomarker data are insufficient to preclude future strategies that target the HSP response, safety data suggest that a higher dose of arimoclomol would not have been tolerated. FUNDING Orphazyme.
Collapse
Affiliation(s)
- Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.
| | | | - Dror Rom
- Prosoft Clinical, Chesterbrook, PA, USA
| | | | | | - William Camu
- Department of Neurology University of Montpellier, CHU Montpellier, INM INSERM, Montpellier, France
| | | | | | - Raul Juntas Morales
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Adriano Chio
- Rita Levi Montalcini Department of Neuroscience, University of Torino, Torino, Italy
| | - Peter M Andersen
- Department of Clinical Sciences, Neuroscience, Umeå University, Umeå, Sweden
| | | | - Dale Lange
- Department of Neurology, Hospital for Special Surgery, New York, NY, USA
| | - Philip Van Damme
- Department of Neurology, University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Gabriele Mora
- Istituti Clinici Scientifici Maugeri, IRCCS Milano, Milan, Italy
| | - Mariusz Grudniak
- Research and Development Department, Polish Stem Cell Bank, Warsaw, Poland
| | - Matthew Elliott
- University of Virginia Medical Center, Charlottesville, VA, USA
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Nicholas Olney
- Providence Portland Medical Center, Providence Brain and Spine Institute, Portland, OR, USA
| | - Shafeeq Ladha
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Namita A Goyal
- Department of Neurology, University of California Irvine, Irvine, CA, USA
| | - Thomas Meyer
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael G Hanna
- University College London, National Hospital for Neurology and Neurosurgery, London, UK
| | - Colin Quinn
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela Genge
- Department of Neurology, Montreal Neurological Institute, Montreal, QC, Canada
| | - Lorne Zinman
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Duaa Jabari
- Department of Neurology, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Christen Shoesmith
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | | | - Christoph Neuwirth
- Neuromuscular Disease Unit/ALS Clinic, Kantonspital St Gallen, St Gallen, Switzerland
| | | | - Jeremy M Shefner
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Joanne Wuu
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | | |
Collapse
|
3
|
Wohnrade C, Seeliger T, Gingele S, Bjelica B, Skripuletz T, Petri S. Diagnostic value of neurofilaments in differentiating motor neuron disease from multifocal motor neuropathy. J Neurol 2024:10.1007/s00415-024-12355-8. [PMID: 38683209 DOI: 10.1007/s00415-024-12355-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To evaluate the performance of serum neurofilament light chain (NfL) and cerebrospinal fluid (CSF) phosphorylated neurofilament heavy chain (pNfH) as diagnostic biomarkers for the differentiation between motor neuron disease (MND) and multifocal motor neuropathy (MMN). METHODS This retrospective, monocentric study included 16 patients with MMN and 34 incident patients with MND. A subgroup of lower motor neuron (MN) dominant MND patients (n = 24) was analyzed separately. Serum NfL was measured using Ella automated immunoassay, and CSF pNfH was measured using enzyme-linked immunosorbent assay. Area under the curve (AUC), optimal cutoff values (Youden's index), and correlations with demographic characteristics were calculated. RESULTS Neurofilament concentrations were significantly higher in MND compared to MMN (p < 0.001), and serum NfL and CSF pNfH correlated strongly with each other (Spearman's rho 0.68, p < 0.001). Serum NfL (AUC 0.946, sensitivity and specificity 94%) and CSF pNfH (AUC 0.937, sensitivity 90.0%, specificity 100%) performed excellent in differentiating MND from MMN. Optimal cutoff values were ≥ 44.15 pg/mL (serum NfL) and ≥ 715.5 pg/mL (CSF pNfH), respectively. Similar results were found when restricting the MND cohort to lower MN dominant patients. Only one MMN patient had serum NfL above the cutoff. Two MND patients presented with neurofilament concentrations below the cutoffs, both featuring a slowly progressive disease. CONCLUSION Neurofilaments are valuable supportive biomarkers for the differentiation between MND and MMN. Serum NfL and CSF pNfH perform similarly well and elevated neurofilaments in case of diagnostic uncertainty underpin MND diagnosis.
Collapse
Affiliation(s)
- Camilla Wohnrade
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany.
| | - Tabea Seeliger
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Bogdan Bjelica
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
- Center for Systems Neuroscience (ZSN) Hannover, 30559, Hannover, Germany
| |
Collapse
|
4
|
Kim SH, Oh KW, Noh MY, Kwon MS. Optimal Therapeutic Strategy of Bone Marrow-Originated Autologous Mesenchymal Stromal/Stem Cells for ALS. Stem Cells Transl Med 2024; 13:309-316. [PMID: 38244235 PMCID: PMC11016834 DOI: 10.1093/stcltm/szad095] [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: 09/30/2023] [Accepted: 12/08/2023] [Indexed: 01/22/2024] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is characterized by selective and progressive neurodegenerative changes in motor neural networks. Given the system complexity, including anatomically distributed sites of degeneration from the motor cortex to the spinal cord and chronic pro-inflammatory conditions, a cell-based therapeutic strategy could be an alternative approach to treating ALS. Lessons from previous mesenchymal stromal/stem cell (MSC) trials in ALS realized the importance of 3 aspects in current and future MSC therapy, including the preparation of MSCs, administration routes and methods, and recipient-related factors. This review briefly describes the current status and future prerequisites for an optimal strategy using bone-marrow-originated MSCs to treat ALS. We suggest mandatory factors in the optimized therapeutic strategy focused on advanced therapy medicinal products produced according to Good Manufacturing Practice, an optimal administration method, the selection of proper patients, and the importance of biomarkers.
Collapse
Affiliation(s)
- Seung Hyun Kim
- Department of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea
- Cell Therapy Center, Hanyang University Hospital, Seoul, Republic of Korea
| | - Ki-Wook Oh
- Department of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea
- Cell Therapy Center, Hanyang University Hospital, Seoul, Republic of Korea
| | - Min-Young Noh
- Department of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea
- Cell Therapy Center, Hanyang University Hospital, Seoul, Republic of Korea
| | - Min-Soo Kwon
- Department of Pharmacology, Research Institute of Basic Medical Science, School of Medicine, CHA University, CHA Bio Complex, Gyeonggi-do, Republic of Korea
| |
Collapse
|
5
|
van Unnik JWJ, Meyjes M, Janse van Mantgem MR, van den Berg LH, van Eijk RPA. Remote monitoring of amyotrophic lateral sclerosis using wearable sensors detects differences in disease progression and survival: a prospective cohort study. EBioMedicine 2024; 103:105104. [PMID: 38582030 PMCID: PMC11004066 DOI: 10.1016/j.ebiom.2024.105104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND There is an urgent need for objective and sensitive measures to quantify clinical disease progression and gauge the response to treatment in clinical trials for amyotrophic lateral sclerosis (ALS). Here, we evaluate the ability of an accelerometer-derived outcome to detect differential clinical disease progression and assess its longitudinal associations with overall survival in patients with ALS. METHODS Patients with ALS wore an accelerometer on the hip for 3-7 days, every 2-3 months during a multi-year observation period. An accelerometer-derived outcome, the Vertical Movement Index (VMI), was calculated, together with predicted disease progression rates, and jointly analysed with overall survival. The clinical utility of VMI was evaluated using comparisons to patient-reported functionality, while the impact of various monitoring schemes on empirical power was explored through simulations. FINDINGS In total, 97 patients (70.1% male) wore the accelerometer for 1995 days, for a total of 27,701 h. The VMI was highly discriminatory for predicted disease progression rates, revealing faster rates of decline in patients with a worse predicted prognosis compared to those with a better predicted prognosis (p < 0.0001). The VMI was strongly associated with the hazard for death (HR 0.20, 95% CI: 0.09-0.44, p < 0.0001), where a decrease of 0.19-0.41 unit was associated with reduced ambulatory status. Recommendations for future studies using accelerometery are provided. INTERPRETATION The results serve as motivation to incorporate accelerometer-derived outcomes in clinical trials, which is essential for further validation of these markers to meaningful endpoints. FUNDING Stichting ALS Nederland (TRICALS-Reactive-II).
Collapse
Affiliation(s)
- Jordi W J van Unnik
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Myrte Meyjes
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mark R Janse van Mantgem
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ruben P A van Eijk
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands; Biostatistics & Research Support, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands.
| |
Collapse
|
6
|
Dukic S, Fasano A, Coffey A, Buxó T, McMackin R, Chipika R, Heverin M, Bede P, Muthuraman M, Lowery M, Carson RG, Hardiman O, Nasseroleslami B. Electroencephalographic β-band oscillations in the sensorimotor network reflect motor symptom severity in amyotrophic lateral sclerosis. Eur J Neurol 2024; 31:e16201. [PMID: 38235854 DOI: 10.1111/ene.16201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/27/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND PURPOSE Resting-state electroencephalography (EEG) holds promise for assessing brain networks in amyotrophic lateral sclerosis (ALS). We investigated whether neural β-band oscillations in the sensorimotor network could serve as an objective quantitative measure of progressive motor impairment and functional disability in ALS patients. METHODS Resting-state EEG was recorded in 18 people with ALS and 38 age- and gender-matched healthy controls. We estimated source-localized β-band spectral power in the sensorimotor cortex. Clinical evaluation included lower (LMN) and upper motor neuron scores, Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised score, fine motor function (FMF) subscore, and progression rate. Correlations between clinical scores and β-band power were analysed and corrected using a false discovery rate of q = 0.05. RESULTS β-Band power was significantly lower in people with ALS than controls (p = 0.004), and correlated with LMN score (R = -0.65, p = 0.013), FMF subscore (R = -0.53, p = 0.036), and FMF progression rate (R = 0.52, p = 0.036). CONCLUSIONS β-Band spectral power in the sensorimotor cortex reflects clinically evaluated motor impairment in ALS. This technology merits further investigation as a biomarker of progressive functional disability.
Collapse
Affiliation(s)
- Stefan Dukic
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
- Department of Neurology, University Medical Centre Utrecht Brain Centre, Utrecht University, Utrecht, the Netherlands
| | - Antonio Fasano
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Amina Coffey
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Teresa Buxó
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Roisin McMackin
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
- Discipline of Physiology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Rangariroyashe Chipika
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Mark Heverin
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group, Trinity Biomedical Sciences Institute, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Muthuraman Muthuraman
- Neural Engineering With Signal Analytics and Artificial Intelligence, Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Madeleine Lowery
- School of Electrical and Electronic Engineering, University College Dublin, Dublin, Ireland
| | - Richard G Carson
- Trinity College Institute of Neuroscience and School of Psychology, Trinity College Dublin, University of Dublin, Dublin, Ireland
- School of Psychology, Queen's University Belfast, Belfast, Ireland
| | - Orla Hardiman
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Bahman Nasseroleslami
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| |
Collapse
|
7
|
Genuis SK, Luth W, Magnussen C, Vande Velde C, Taylor D, Johnston WS. Patient engagement in research: lessons learned from CAPTURE ALS, a longitudinal observational ALS study. Amyotroph Lateral Scler Frontotemporal Degener 2024:1-10. [PMID: 38519870 DOI: 10.1080/21678421.2024.2328599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/04/2024] [Indexed: 03/25/2024]
Abstract
Objective: There are compelling ethical and practical reasons for patient engagement in research (PEIR), however, evidence for best practices remains limited. We investigated PEIR as implemented in CAPTURE ALS, a longitudinal observational study, from study inception through the first 2.5 years of operations. Methods: Data were drawn from three engagement initiatives: a community-led letter-writing campaign; consultation with patient and caregiver focus groups; and a study-embedded 'participant partner advisory council' (PPAC). Data were derived retrospectively from study documentation. We used the International Association of Public Participation (IAP2) participation spectrum as a framework for investigation. Results: 2401 letters from community members to the Canadian government affirmed study objectives and advocated for funding. Feedback from focus group consultation influenced study design and supported the study's data-sharing plan. PPAC collaboration shaped all aspects of the study. Contributions included: co-creation of governance documents, input on study protocols and public-facing communication, and development of engagement webinars for study participants and feedback surveys. Effective communication practices fostered collaboration and helped avoid tokenistic engagement. CAPTURE ALS encompassed all IAP2 participation levels. Conclusions: CAPTURE ALS was shaped by meaningful engagement initiatives over the course of the study. Lessons learned included: begin early and embed PEIR within research; build relationships and foster mutual learning; be flexible, open to adaptation, and seek diversity. Primary challenges included funding for early implementation, time needed to maintain relationships, and attrition due to disease progression. All IAP2 participation levels contributed to meaningful PEIR. 'Empowerment' was demonstrated through advocacy.
Collapse
Affiliation(s)
- Shelagh K Genuis
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Westerly Luth
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Claire Magnussen
- Montreal Neurological Institute-Hospital, McGill University, Montreal, QC, Canada
| | | | | | - Wendy S Johnston
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
8
|
Beswick E, Johnson M, Newton J, Dakin R, Stenson A, Abrahams S, Carson A, Chandran S, Pal S. Factors impacting trial participation in people with motor neuron disease. J Neurol 2024; 271:543-552. [PMID: 37787812 PMCID: PMC10769905 DOI: 10.1007/s00415-023-12010-8] [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: 07/21/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 10/04/2023]
Abstract
Motor neuron disease (MND) is a rapidly progressive neurodegenerative disorder with limited treatment options. Historically, neurological trials have been plagued by suboptimal recruitment and high rates of attrition. The Motor Neuron Disease-Systematic Multi-Arm Randomised Adaptive Trial (MND-SMART) seeks to identify effective disease modifying drugs. This study investigates person-specific factors affecting recruitment and retention. Improved understanding of these factors may improve trial protocol design, optimise recruitment and retention. Participants with MND completed questionnaires and this was supplemented with clinical data. 12 months after completing the questionnaires we used MND-SMART recruitment data to establish if members of our cohort engaged with the trial. 120 people with MND completed questionnaires for this study. Mean age at participation was 66 (SD = 9), 14% (n = 17) were categorised as long survivors, with 68% (n = 81) of participants male and 60% (n = 73) had the ALS sub-type. Of the 120 study participants, 50% (n = 60) were randomised into MND-SMART and 78% (n = 94) expressed interest an in participating. After the 1-year follow-up period 65% (n = 39) of the 60 randomised participants remained in MND-SMART. Older age was significantly associated with reduced likelihood of participation (OR = 0.92, 95% CI = 0.88-0.96, p = 0.000488). The findings show that people with MND are highly motivated to engage in research, but older individuals remain significantly less likely to participate. We recommend the inclusion of studies to explore characteristics of prospective and current participants alongside trials.
Collapse
Affiliation(s)
- Emily Beswick
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland
- Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland
| | - Micheala Johnson
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland
- Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland
| | - Judith Newton
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland
- Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland
| | - Rachel Dakin
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland
- Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland
| | - Amy Stenson
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland
- Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland
| | - Sharon Abrahams
- Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland
- Human Cognitive Neurosciences, Psychology, School of Philosophy, Psychology and Language Sciences, The University of Edinburgh, Edinburgh, Scotland
| | - Alan Carson
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland
- Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Suvankar Pal
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland.
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland.
- Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland.
| |
Collapse
|
9
|
Martinelli I, Zucchi E, Simonini C, Gianferrari G, Bedin R, Biral C, Ghezzi A, Fini N, Carra S, Mandrioli J. SerpinA1 levels in amyotrophic lateral sclerosis patients: An exploratory study. Eur J Neurol 2024; 31:e16054. [PMID: 37679868 DOI: 10.1111/ene.16054] [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: 05/17/2023] [Revised: 07/31/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND SerpinA1, a serine protease inhibitor, is involved in the modulation of microglial-mediated inflammation in neurodegenerative diseases. We explored SerpinA1 levels in cerebrospinal fluid (CSF) and serum of amyotrophic lateral sclerosis (ALS) patients to understand its potential role in the pathogenesis of the disease. METHODS SerpinA1, neurofilament light (NfL) and heavy (NfH) chain, and chitinase-3-like protein-1 (CHI3L1) were determined in CSF and serum of ALS patients (n = 110) and healthy controls (n = 10) (automated next-generation ELISA), and correlated with clinical parameters, after identifying three classes of progressors (fast, intermediate, slow). Biomarker levels were analyzed for diagnostic power and association with progression and survival. RESULTS SerpinA1serum was significantly decreased in ALS (median: 1032 μg/mL) compared with controls (1343 μg/mL) (p = 0.02). SerpinA1CSF was elevated only in fast progressors (8.6 μg/mL) compared with slow (4.43 μg/mL, p = 0.01) and intermediate (4.42 μg/mL, p = 0.03) progressors. Moreover, SerpinA1CSF correlated with neurofilament and CHI3L1 levels in CSF. Contrarily to SerpinA1CSF , neurofilament and CHI3L1 concentrations in CSF correlated with measures of disease progression in ALS, while SerpinA1serum mildly related with time to generalization (rho = 0.20, p = 0.04). In multivariate analysis, the ratio between serum and CSF SerpinA1 (SerpinA1 ratio) and NfHCSF were independently associated with survival. CONCLUSIONS Higher SerpinA1CSF levels are found in fast progressors, suggesting SerpinA1 is a component of the neuroinflammatory mechanisms acting upon fast-progressing forms of ALS. Both neurofilaments or CHI3L1CSF levels outperformed SerpinA1 at predicting disease progression rate in our cohort, and so the prognostic value of SerpinA1 alone as a measure remains inconclusive.
Collapse
Affiliation(s)
- Ilaria Martinelli
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Elisabetta Zucchi
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
- Neuroscience PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Cecilia Simonini
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Giulia Gianferrari
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberta Bedin
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Chiara Biral
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Ghezzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Fini
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Serena Carra
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Jessica Mandrioli
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
10
|
Beswick E, Forbes D, Johnson M, Newton J, Dakin R, Glasmcher S, Abrahams S, Carson A, Chandran S, Pal S. Non-motor symptoms in motor neuron disease: prevalence, assessment and impact. Brain Commun 2023; 6:fcad336. [PMID: 38162906 PMCID: PMC10754319 DOI: 10.1093/braincomms/fcad336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/27/2023] [Accepted: 12/05/2023] [Indexed: 01/03/2024] Open
Abstract
People with motor neuron disease often experience non-motor symptoms that may occur secondary to, or distinct from, motor degeneration and that may significantly reduce quality of life, despite being under-recognized and evaluated in clinical practice. Non-motor symptoms explored in this population-based study include pain, fatigue, gastrointestinal issues, poor sleep, low mood, anxiety, problematic saliva, apathy, emotional lability, cognitive complaints and sexual dysfunction. People registered on the Clinical Audit Research and Evaluation of motor neuron disease platform, the Scottish Motor Neuron Disease Register, were invited to complete a questionnaire on non-motor symptoms and a self-reported Amyotrophic Lateral Sclerosis Functional Rating Scale. The questionnaire comprised a pre-defined list of 11 potential non-motor symptoms, with the opportunity to list additional symptoms. A total of 120 individuals participated in this cross-sectional study, a 39% response rate of those sent questionnaires (n = 311); 99% of participants recruited (n = 120) experienced at least one non-motor symptom, with 72% (n = 120) reporting five or more. The symptoms most often reported were pain and fatigue (reported by 76% of participants, respectively). The symptoms reported to be most impactful were gastrointestinal issues (reported as 'severe' by 54% of participants who experienced them), followed by pain and problematic saliva (51%, respectively). Lower Amyotrophic Lateral Sclerosis Functional Rating Scale scores, indicating more advanced disease and being a long survivor [diagnosed over 8 years ago; Black et al. (Genetic epidemiology of motor neuron disease-associated variants in the Scottish population. Neurobiol Aging. 2017;51:178.e11-178.e20.)], were significantly associated with reporting more symptoms; 73% of respondents were satisfied with the frequency that non-motor symptoms were discussed in clinical care; 80% of participants indicated they believe evaluation of non-motor symptom is important to include as outcomes in trials, independent of their personal experience of these symptoms. The preferred method of assessment was completing questionnaires, at home. The overwhelming majority of people with motor neuron disease report non-motor symptoms and these frequently co-occur. Pain, fatigue, gastrointestinal issues, sleep, mood, anxiety, problematic saliva, apathy, emotional lability, cognitive complaints and sexual dysfunction are prevalent. People with motor neuron disease who had worse physical function and those who were long survivors were more likely to report more symptoms. Where reported, these symptoms are frequent, impactful and a priority for people with motor neuron disease in clinical care and trial design.
Collapse
Affiliation(s)
- Emily Beswick
- Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
| | - Deborah Forbes
- Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
| | - Micheala Johnson
- Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
| | - Judith Newton
- Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
| | - Rachel Dakin
- Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
| | - Stella Glasmcher
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
| | - Sharon Abrahams
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
- Human Cognitive Neurosciences, Psychology, School of Philosophy, Psychology and Language Sciences, the University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, the University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Suvankar Pal
- Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, the University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, the University of Edinburgh, Edinburgh, UK
| |
Collapse
|
11
|
Firstenfeld AJ, Listorti J, Jalaff N, Loaiza Orozco CP, Navarrete Gosdenovich F, Schurr T. Add-on treatment with Cerebrolysin improves clinical symptoms in patients with ALS: results from a prospective, single-center, placebo-controlled, randomized, double-blind, phase II study. J Med Life 2023; 16:1750-1755. [PMID: 38585517 PMCID: PMC10994623 DOI: 10.25122/jml-2023-0459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 04/09/2024] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating and progressive neurodegenerative disease with limited treatment options available. Cerebrolysin is a drug candidate for the treatment of ALS because of its neuroprotective and neuroregenerative effects. We initiated a pilot clinical study of a combination of Cerebrolysin and riluzole to assess the therapeutic benefit of Cerebrolysin as an add-on treatment on clinical signs and symptoms in outpatients with ALS. Twenty patients with a clinically definitive diagnosis of ALS were enrolled and randomly assigned in a 1:1 ratio to receive Cerebrolysin or placebo. All patients received 50 mg of riluzole PO twice daily as a standard treatment. Patients in the Cerebrolysin group received intravenous injections of 10 mL of Cerebrolysin once daily, five days a week for the first month and three days a week for the next two months. Analysis of the ALS Functional Rating Scale - revised at Month 1 (primary outcome measure), showed a significant treatment effect in favor of Cerebrolysin with a 2.3-point improvement from baseline to Month 1 compared to a 0.9-point decrease in patients on placebo (P=0.005). The effect was maintained over the three-month study period, and the beneficial effect of Cerebrolysin over placebo was also evident in the secondary outcome measures. The safety analysis showed that the combination of riluzole and Cerebrolyisn was well tolerated. Our results demonstrate for the first time a significant clinical effect of Cerebrolysin in improving functional outcomes in patients with ALS and suggest that Cerebrolysin has potential as a novel therapeutic option for ALS.
Collapse
Affiliation(s)
- Alfredo José Firstenfeld
- Servicio de Neurociencias, Universidad de Buenos Aires, Instituto Cardiológico Banfield, Buenos Aires, Argentina
| | - Jorge Listorti
- Servicio de Neurociencias, Universidad de Buenos Aires, Instituto Cardiológico Banfield, Buenos Aires, Argentina
| | - Nasser Jalaff
- Servicio de Neurociencias, Universidad de Buenos Aires, Instituto Cardiológico Banfield, Buenos Aires, Argentina
| | | | | | - Timo Schurr
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| |
Collapse
|
12
|
Tröger J, Baltes J, Baykara E, Kasper E, Kring M, Linz N, Robin J, Schäfer S, Schneider A, Hermann A. PROSA-a multicenter prospective observational study to develop low-burden digital speech biomarkers in ALS and FTD. Amyotroph Lateral Scler Frontotemporal Degener 2023:1-10. [PMID: 37516990 DOI: 10.1080/21678421.2023.2239312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/15/2023] [Indexed: 08/01/2023]
Abstract
Objective: There is a need for novel biomarkers that can indicate disease state, project disease progression, or assess response to treatment for amyotrophic lateral sclerosis (ALS) and associated neurodegenerative diseases such as frontotemporal dementia (FTD). Digital biomarkers are especially promising as they can be collected non-invasively and at low burden for patients. Speech biomarkers have the potential to objectively measure cognitive, motor as well as respiratory symptoms at low-cost and in a remote fashion using widely available technology such as telephone calls. Methods: The PROSA study aims to develop and evaluate low-burden frequent prognostic digital speech biomarkers. The main goal is to create a single, easy-to-perform battery that serves as a valid and reliable proxy for cognitive, respiratory, and motor domains in ALS and FTD. The study will be a multicenter 12-months observational study aiming to include 75 ALS and 75 FTD patients as well as 50 healthy controls and build on three established longitudinal cohorts: DANCER, DESCRIBE-ALS and DESCRIBE-FTD. In addition to the extensive clinical phenotyping in DESCRIBE, PROSA collects a comprehensive speech protocol in fully remote and automated fashion over the telephone at four time points. This longitudinal speech data, together with gold standard measures, will allow advanced speech analysis using artificial intelligence for the development of speech-based phenotypes of ALS and FTD patients measuring cognitive, motor and respiratory symptoms. Conclusion: Speech-based phenotypes can be used to develop diagnostic and prognostic models predicting clinical change. Results are expected to have implications for future clinical trial stratification as well as supporting innovative trial designs in ALS and FTD.
Collapse
Affiliation(s)
| | - Judith Baltes
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | | | - Elisabeth Kasper
- German Center for Neurodegenerative Diseases (DZNE) Rostock/Greifswald, Rostock, Germany
- Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Martha Kring
- German Center for Neurodegenerative Diseases (DZNE) Rostock/Greifswald, Rostock, Germany
| | | | | | | | - Anja Schneider
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Bonn, Germany
| | - Andreas Hermann
- German Center for Neurodegenerative Diseases (DZNE) Rostock/Greifswald, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock (CTNR), University Medical Center Rostock, Rostock, Germany, and
- Translational Neurodegeneration Section "Albrecht-Kossel", Department of Neurology, University Medical Center Rostock, Rostock, Germany
| |
Collapse
|
13
|
McCluskey G, Morrison KE, Donaghy C, McConville J, McCarron MO, McVerry F, Duddy W, Duguez S. Serum Neurofilaments in Motor Neuron Disease and Their Utility in Differentiating ALS, PMA and PLS. Life (Basel) 2023; 13:1301. [PMID: 37374084 DOI: 10.3390/life13061301] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Neurofilament levels are elevated in many neurodegenerative diseases and have shown promise as diagnostic and prognostic biomarkers in Amyotrophic Lateral Sclerosis (ALS), the most common form of Motor Neuron Disease (MND). This study assesses serum neurofilament light (NFL) and neurofilament heavy (NFH) chain concentrations in patients with ALS, other variants of motor neuron disease such as Progressive Muscular Atrophy (PMA) and Primary Lateral Sclerosis (PLS), and a range of other neurological diseases. It aims to evaluate the use of NFL and NFH to differentiate these conditions and for the prognosis of MND disease progression. NFL and NFH levels were quantified using electrochemiluminescence immunoassays (ECLIA). Both were elevated in 47 patients with MND compared to 34 patients with other neurological diseases and 33 healthy controls. NFL was able to differentiate patients with MND from the other groups with a Receiver Operating Characteristic (ROC) curve area under the curve (AUC) of 0.90 (p < 0.001). NFL correlated with the rate of disease progression in MND (rho 0.758, p < 0.001) and with the ALS Functional Rating Scale (rho -0.335, p = 0.021). NFL levels were higher in patients with ALS compared to both PMA (p = 0.032) and PLS (p = 0.012) and were able to distinguish ALS from both PMA and PLS with a ROC curve AUC of 0.767 (p = 0.005). These findings support the use of serum NFL to help diagnose and differentiate types of MND, in addition to providing prognostic information to patients and their families.
Collapse
Affiliation(s)
- Gavin McCluskey
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry BT47 6SB, UK
- Department of Neurology, Royal Victoria Hospital, Belfast BT12 6BA, UK
- Department of Neurology, Altnagelvin Hospital, Derry BT47 6SB, UK
| | - Karen E Morrison
- Department of Neurology, Royal Victoria Hospital, Belfast BT12 6BA, UK
- Faculty of Medicine, Health & Life Sciences, Queen's University, Belfast BT9 6AG, UK
| | - Colette Donaghy
- Department of Neurology, Altnagelvin Hospital, Derry BT47 6SB, UK
| | - John McConville
- Department of Neurology, Royal Victoria Hospital, Belfast BT12 6BA, UK
- Department of Neurology, Ulster Hospital, Belfast BT16 1RH, UK
| | - Mark O McCarron
- Department of Neurology, Altnagelvin Hospital, Derry BT47 6SB, UK
| | - Ferghal McVerry
- Department of Neurology, Altnagelvin Hospital, Derry BT47 6SB, UK
| | - William Duddy
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry BT47 6SB, UK
| | - Stephanie Duguez
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry BT47 6SB, UK
| |
Collapse
|
14
|
Sanchez-Tejerina D, Llaurado A, Sotoca J, Lopez-Diego V, Vidal Taboada JM, Salvado M, Juntas-Morales R. Biofluid Biomarkers in the Prognosis of Amyotrophic Lateral Sclerosis: Recent Developments and Therapeutic Applications. Cells 2023; 12:cells12081180. [PMID: 37190090 DOI: 10.3390/cells12081180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Abstract
Amyotrophic lateral sclerosis is a neurodegenerative disease characterized by the degeneration of motor neurons for which effective therapies are lacking. One of the most explored areas of research in ALS is the discovery and validation of biomarkers that can be applied to clinical practice and incorporated into the development of innovative therapies. The study of biomarkers requires an adequate theoretical and operational framework, highlighting the "fit-for-purpose" concept and distinguishing different types of biomarkers based on common terminology. In this review, we aim to discuss the current status of fluid-based prognostic and predictive biomarkers in ALS, with particular emphasis on those that are the most promising ones for clinical trial design and routine clinical practice. Neurofilaments in cerebrospinal fluid and blood are the main prognostic and pharmacodynamic biomarkers. Furthermore, several candidates exist covering various pathological aspects of the disease, such as immune, metabolic and muscle damage markers. Urine has been studied less often and should be explored for its possible advantages. New advances in the knowledge of cryptic exons introduce the possibility of discovering new biomarkers. Collaborative efforts, prospective studies and standardized procedures are needed to validate candidate biomarkers. A combined biomarkers panel can provide a more detailed disease status.
Collapse
Affiliation(s)
- Daniel Sanchez-Tejerina
- Neuromuscular Diseases Unit, Neurology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Peripheral Nervous System Group, Vall d'Hebron Research Institut (VHIR), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Medicine Department, Universitat Autónoma de Barcelona, 08035 Barcelon, Spain
| | - Arnau Llaurado
- Neuromuscular Diseases Unit, Neurology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Peripheral Nervous System Group, Vall d'Hebron Research Institut (VHIR), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Javier Sotoca
- Neuromuscular Diseases Unit, Neurology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Peripheral Nervous System Group, Vall d'Hebron Research Institut (VHIR), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Veronica Lopez-Diego
- Neuromuscular Diseases Unit, Neurology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Peripheral Nervous System Group, Vall d'Hebron Research Institut (VHIR), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Jose M Vidal Taboada
- Peripheral Nervous System Group, Vall d'Hebron Research Institut (VHIR), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Medicine Department, Universitat Autónoma de Barcelona, 08035 Barcelon, Spain
| | - Maria Salvado
- Neuromuscular Diseases Unit, Neurology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Peripheral Nervous System Group, Vall d'Hebron Research Institut (VHIR), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Raul Juntas-Morales
- Neuromuscular Diseases Unit, Neurology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Peripheral Nervous System Group, Vall d'Hebron Research Institut (VHIR), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Medicine Department, Universitat Autónoma de Barcelona, 08035 Barcelon, Spain
| |
Collapse
|
15
|
Mead RJ, Shan N, Reiser HJ, Marshall F, Shaw PJ. Amyotrophic lateral sclerosis: a neurodegenerative disorder poised for successful therapeutic translation. Nat Rev Drug Discov 2023; 22:185-212. [PMID: 36543887 PMCID: PMC9768794 DOI: 10.1038/s41573-022-00612-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 12/24/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating disease caused by degeneration of motor neurons. As with all major neurodegenerative disorders, development of disease-modifying therapies has proven challenging for multiple reasons. Nevertheless, ALS is one of the few neurodegenerative diseases for which disease-modifying therapies are approved. Significant discoveries and advances have been made in ALS preclinical models, genetics, pathology, biomarkers, imaging and clinical readouts over the last 10-15 years. At the same time, novel therapeutic paradigms are being applied in areas of high unmet medical need, including neurodegenerative disorders. These developments have evolved our knowledge base, allowing identification of targeted candidate therapies for ALS with diverse mechanisms of action. In this Review, we discuss how this advanced knowledge, aligned with new approaches, can enable effective translation of therapeutic agents from preclinical studies through to clinical benefit for patients with ALS. We anticipate that this approach in ALS will also positively impact the field of drug discovery for neurodegenerative disorders more broadly.
Collapse
Affiliation(s)
- Richard J Mead
- Sheffield Institute for Translational Neuroscience, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
- Neuroscience Institute, University of Sheffield, Sheffield, UK
- Keapstone Therapeutics, The Innovation Centre, Broomhall, Sheffield, UK
| | - Ning Shan
- Aclipse Therapeutics, Radnor, PA, US
| | | | - Fiona Marshall
- MSD UK Discovery Centre, Merck, Sharp and Dohme (UK) Limited, London, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK.
- Neuroscience Institute, University of Sheffield, Sheffield, UK.
- Keapstone Therapeutics, The Innovation Centre, Broomhall, Sheffield, UK.
| |
Collapse
|
16
|
Wong C, Gregory JM, Liao J, Egan K, Vesterinen HM, Ahmad Khan A, Anwar M, Beagan C, Brown FS, Cafferkey J, Cardinali A, Chiam JY, Chiang C, Collins V, Dormido J, Elliott E, Foley P, Foo YC, Fulton-Humble L, Gane AB, Glasmacher SA, Heffernan Á, Jayaprakash K, Jayasuriya N, Kaddouri A, Kiernan J, Langlands G, Leighton D, Liu J, Lyon J, Mehta AR, Meng A, Nguyen V, Park NH, Quigley S, Rashid Y, Salzinger A, Shiell B, Singh A, Soane T, Thompson A, Tomala O, Waldron FM, Selvaraj BT, Chataway J, Swingler R, Connick P, Pal S, Chandran S, Macleod M. Systematic, comprehensive, evidence-based approach to identify neuroprotective interventions for motor neuron disease: using systematic reviews to inform expert consensus. BMJ Open 2023; 13:e064169. [PMID: 36725099 PMCID: PMC9896226 DOI: 10.1136/bmjopen-2022-064169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 01/10/2023] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES Motor neuron disease (MND) is an incurable progressive neurodegenerative disease with limited treatment options. There is a pressing need for innovation in identifying therapies to take to clinical trial. Here, we detail a systematic and structured evidence-based approach to inform consensus decision making to select the first two drugs for evaluation in Motor Neuron Disease-Systematic Multi-arm Adaptive Randomised Trial (MND-SMART: NCT04302870), an adaptive platform trial. We aim to identify and prioritise candidate drugs which have the best available evidence for efficacy, acceptable safety profiles and are feasible for evaluation within the trial protocol. METHODS We conducted a two-stage systematic review to identify potential neuroprotective interventions. First, we reviewed clinical studies in MND, Alzheimer's disease, Huntington's disease, Parkinson's disease and multiple sclerosis, identifying drugs described in at least one MND publication or publications in two or more other diseases. We scored and ranked drugs using a metric evaluating safety, efficacy, study size and study quality. In stage two, we reviewed efficacy of drugs in MND animal models, multicellular eukaryotic models and human induced pluripotent stem cell (iPSC) studies. An expert panel reviewed candidate drugs over two shortlisting rounds and a final selection round, considering the systematic review findings, late breaking evidence, mechanistic plausibility, safety, tolerability and feasibility of evaluation in MND-SMART. RESULTS From the clinical review, we identified 595 interventions. 66 drugs met our drug/disease logic. Of these, 22 drugs with supportive clinical and preclinical evidence were shortlisted at round 1. Seven drugs proceeded to round 2. The panel reached a consensus to evaluate memantine and trazodone as the first two arms of MND-SMART. DISCUSSION For future drug selection, we will incorporate automation tools, text-mining and machine learning techniques to the systematic reviews and consider data generated from other domains, including high-throughput phenotypic screening of human iPSCs.
Collapse
Affiliation(s)
- Charis Wong
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Jenna M Gregory
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Jing Liao
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Kieren Egan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Computer and Information Science, University of Strathclyde, Glasgow, UK
| | - Hanna M Vesterinen
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Aimal Ahmad Khan
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Maarij Anwar
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Caitlin Beagan
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Fraser S Brown
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - John Cafferkey
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Alessandra Cardinali
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Jane Yi Chiam
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Claire Chiang
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Victoria Collins
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | | | - Elizabeth Elliott
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Peter Foley
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Yu Cheng Foo
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | | | - Angus B Gane
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Stella A Glasmacher
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Áine Heffernan
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Kiran Jayaprakash
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Nimesh Jayasuriya
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Amina Kaddouri
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Jamie Kiernan
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Gavin Langlands
- Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - D Leighton
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- School of Psychology and Neuroscience, University of Glasgow, Glasgow, UK
| | - Jiaming Liu
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - James Lyon
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Arpan R Mehta
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Alyssa Meng
- Centre for Discovery Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Vivienne Nguyen
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Na Hyun Park
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Suzanne Quigley
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Yousuf Rashid
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Andrea Salzinger
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Bethany Shiell
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Ankur Singh
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Tim Soane
- Neurology Department, NHS Forth Valley, Stirling, UK
| | - Alexandra Thompson
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Olaf Tomala
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Fergal M Waldron
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
- Institute of Evolutionary Biology, The University of Edinburgh, Edinburgh, UK
| | - Bhuvaneish T Selvaraj
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Jeremy Chataway
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, London, UK
- University College London Hospitals, Biomedical Research Centre, National Institute for Health Research, London, UK
| | - Robert Swingler
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
| | - Peter Connick
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Suvankar Pal
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Siddharthan Chandran
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, The University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| |
Collapse
|
17
|
Yunusova Y, Waito A, Barnett Tapia C, Huynh A, Martino R, Abrahao A, Pattee GL, Berry JD, Zinman L, Green JR. Face and content validation of the amyotrophic lateral sclerosis-Bulbar dysfunction index (ALS-BDI). Front Neurol 2023; 13:1078612. [PMID: 36686519 PMCID: PMC9849694 DOI: 10.3389/fneur.2022.1078612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/08/2022] [Indexed: 01/06/2023] Open
Abstract
Purpose Early detection and tracking of bulbar dysfunction in amyotrophic lateral sclerosis (ALS) are critical for directing management of the disease. Existing physiological assessments of bulbar dysfunction are often inaccessible and cost-prohibitive for clinical application. Existing clinical assessments are limited. The overall goal of our research is to develop a brief and reliable, clinician-administered assessment tool, the ALS Bulbar Dysfunction Index (ALS-BDI) to evaluate bulbar dysfunction. The aim of this study was to establish content and face validity of the ALS-BDI through item generation and reduction, including item scoring. Methods The design of the ALS-BDI followed guidelines outlined by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). The design stage of the ALS-BDI involved two steps: (Step 1) the generation of candidate items from a literature review of commonly used clinical tools, and selection of items following a review of item reliability and item relevance and expert consensus; (Step 2) the assessment of their content and face validity via online survey feedback from experts (n = 35). The initial design was followed by a semi-structured cognitive interview with Speech-Language Pathologists (n = 5) to finalize a testable draft of the instrument. Results Two drafts of the ALS-BDI were developed. The first draft contained 48 items, after a review of existing clinical tools for their relevance to bulbar dysfunction in ALS. Of the 48 items, 35 items were retained after surveying experts and clinician users for their relevance, feasibility, interpretability, and appropriateness. The second draft of the ALS-BDI contained 37 items, due to one item splitting, based on users cognitive interviews. Conclusions The ALS-BDI described in this study aims to provide a brief and reliable, clinician-administered assessment tool to evaluate bulbar dysfunction in patients with ALS. Future research will evaluate the psychometric properties of this tool including its reliability, validity, and responsiveness to change over time.
Collapse
Affiliation(s)
- Yana Yunusova
- Department of Speech-Language Pathology, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada,KITE – University Health Network, Toronto, ON, Canada,*Correspondence: Yana Yunusova ✉
| | - Ashley Waito
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Carolina Barnett Tapia
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON, Canada,Dalla Lana School of Public Health, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Anna Huynh
- Department of Speech-Language Pathology, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada,KITE – University Health Network, Toronto, ON, Canada
| | - Rosemary Martino
- Department of Speech-Language Pathology, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada,Department of Otolaryngology – Head and Neck Surgery, University of Toronto, Toronto, ON, Canada,Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Agessandro Abrahao
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON, Canada,Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - James D. Berry
- Sean M. Healey and AMG Center for ALS, Massachusetts General Hospital, Boston, MA, United States
| | - Lorne Zinman
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON, Canada,Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jordan R. Green
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA, United States,Speech and Hearing Bioscience and Technology, Harvard University, Boston, MA, United States
| |
Collapse
|
18
|
Canosa A, Martino A, Manera U, Vasta R, Grassano M, Palumbo F, Cabras S, Di Pede F, Arena V, Moglia C, Giuliani A, Calvo A, Chiò A, Pagani M. Role of brain 2-[ 18F]fluoro-2-deoxy-D-glucose-positron-emission tomography as survival predictor in amyotrophic lateral sclerosis. Eur J Nucl Med Mol Imaging 2023; 50:784-791. [PMID: 36308536 PMCID: PMC9852209 DOI: 10.1007/s00259-022-05987-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/29/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE The identification of prognostic tools in amyotrophic lateral sclerosis (ALS) would improve the design of clinical trials, the management of patients, and life planning. We aimed to evaluate the accuracy of brain 2-[18F]fluoro-2-deoxy-D-glucose-positron-emission tomography (2-[18F]FDG-PET) as an independent predictor of survival in ALS. METHODS A prospective cohort study enrolled 418 ALS patients, who underwent brain 2-[18F]FDG-PET at diagnosis and whose survival time was available. We discretized the survival time in a finite number of classes in a data-driven fashion by employing a k-means-like strategy. We identified "hot brain regions" with maximal power in discriminating survival classes, by evaluating the Laplacian scores in a class-aware fashion. We retained the top-m features for each class to train the classification systems (i.e., a support vector machine, SVM), using 10% of the ALS cohort as test set. RESULTS Data were discretized in three survival profiles: 0-2 years, 2-5 years, and > 5 years. SVM resulted in an error rate < 20% for two out of three classes separately. As for class one, the discriminant clusters included left caudate body and anterior cingulate cortex. The most discriminant regions were bilateral cerebellar pyramid in class two, and right cerebellar dentate nucleus, and left cerebellar nodule in class three. CONCLUSION Brain 2-[18F]FDG-PET along with artificial intelligence was able to predict with high accuracy the survival time range in our ALS cohort. Healthcare professionals can benefit from this prognostic tool for planning patients' management and follow-up. 2-[18F]FDG-PET represents a promising biomarker for individual patients' stratification in clinical trials. The lack of a multicentre external validation of the model warrants further studies to evaluate its generalization capability.
Collapse
Affiliation(s)
- Antonio Canosa
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy ,grid.432329.d0000 0004 1789 4477SC Neurologia 1U, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy ,grid.428479.40000 0001 2297 9633Institute of Cognitive Sciences and Technologies, C.N.R., Rome, Italy
| | - Alessio Martino
- grid.428479.40000 0001 2297 9633Institute of Cognitive Sciences and Technologies, C.N.R., Rome, Italy ,grid.18038.320000 0001 2180 8787Department of Business and Management, LUISS University, Viale Romania 32, 00197 Rome, Italy
| | - Umberto Manera
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy ,grid.432329.d0000 0004 1789 4477SC Neurologia 1U, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Rosario Vasta
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Maurizio Grassano
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Francesca Palumbo
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Sara Cabras
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Francesca Di Pede
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Vincenzo Arena
- Positron Emission Tomography Centre AFFIDEA-IRMET S.p.A., Turin, Italy
| | - Cristina Moglia
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy ,grid.432329.d0000 0004 1789 4477SC Neurologia 1U, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Alessandro Giuliani
- Environment and Health Department, Istituto Superiore di Sanità, Rome, Italy
| | - Andrea Calvo
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy ,grid.432329.d0000 0004 1789 4477SC Neurologia 1U, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy ,grid.7605.40000 0001 2336 6580Neuroscience Institute of Turin (NIT), Turin, Italy
| | - Adriano Chiò
- grid.7605.40000 0001 2336 6580ALS Centre, “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy ,grid.432329.d0000 0004 1789 4477SC Neurologia 1U, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy ,grid.428479.40000 0001 2297 9633Institute of Cognitive Sciences and Technologies, C.N.R., Rome, Italy ,grid.7605.40000 0001 2336 6580Neuroscience Institute of Turin (NIT), Turin, Italy
| | - Marco Pagani
- grid.428479.40000 0001 2297 9633Institute of Cognitive Sciences and Technologies, C.N.R., Rome, Italy ,grid.24381.3c0000 0000 9241 5705Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
19
|
Sexual Dimorphism in Neurodegenerative Diseases and in Brain Ischemia. Biomolecules 2022; 13:biom13010026. [PMID: 36671411 PMCID: PMC9855831 DOI: 10.3390/biom13010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022] Open
Abstract
Epidemiological studies and clinical observations show evidence of sexual dimorphism in brain responses to several neurological conditions. It is suggested that sex-related differences between men and women may have profound effects on disease susceptibility, pathophysiology, and progression. Sexual differences of the brain are achieved through the complex interplay of several factors contributing to this phenomenon, such as sex hormones, as well as genetic and epigenetic differences. Despite recent advances, the precise link between these factors and brain disorders is incompletely understood. This review aims to briefly outline the most relevant aspects that differ between men and women in ischemia and neurodegenerative disorders (AD, PD, HD, ALS, and SM). Recognition of disparities between both sexes could aid the development of individual approaches to ameliorate or slow the progression of intractable disorders.
Collapse
|
20
|
Kobayakawa Y, Todaka K, Hashimoto Y, Ko S, Shiraishi W, Kishimoto J, Kira JI, Yamasaki R, Isobe N. A novel quantitative indicator for disease progression rate in amyotrophic lateral sclerosis. J Neurol Sci 2022; 442:120389. [PMID: 36041329 DOI: 10.1016/j.jns.2022.120389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/16/2022] [Accepted: 08/20/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The current study sought to develop a new indicator for disease progression rate in amyotrophic lateral sclerosis (ALS). METHODS We used a nonparametric method to score diverse patterns of decline in the percentage of predicted forced vital capacity (%FVC) in patients with ALS. This involved 6317 longitudinal %FVC data sets from 920 patients in the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) database volunteered by PRO-ACT Consortium members. To assess the utility of the derived scores as a disease indicator, we examined changes over time, the association with prognosis, and correlation with the Risk Profile of the Treatment Research Initiative to Cure ALS (TRICALS). Our local cohort (n = 92) was used for external validation. RESULTS We derived scores ranging from 35 to 106 points to construct the FVC Decline Pattern scale (FVC-DiP). Individuals' FVC-DiP scores were determined from a single measurement of %FVC and disease duration at assessment. Although the %FVC declined over the disease course (p < 0.0001), the FVC-DiP remained relatively stable. Low FVC-DiP scores were associated with rapid disease progression. Using our cohort, we demonstrated an association between FVC-DiP and the survival prognosis, the stability of the FVC-DiP per individual, and a correlation between FVC-DiP scores and the TRICALS Risk Profile (r2 = 0.904, p < 0.0001). CONCLUSIONS FVC-DiP scores reflected patterns of declining %FVC over the natural course of ALS and indicated the disease progression rate. The FVC-DiP may enable easy assessment of disease progression patterns and could be used for assessing treatment efficacy.
Collapse
Affiliation(s)
- Yuko Kobayakawa
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan; Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Koji Todaka
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Yu Hashimoto
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Senri Ko
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Wataru Shiraishi
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Junji Kishimoto
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan; Translational Neuroscience Center, Graduate School of Medicine, School of Pharmacy at Fukuoka, International University of Health and Welfare, Okawa, Fukuoka 831-8501, Japan; Department of Neurology, Brain and Nerve Center, Fukuoka Central Hospital, International University of Health and Welfare, Fukuoka 810-0022, Japan
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Noriko Isobe
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan.
| | | |
Collapse
|
21
|
McMillan CT, Wuu J, Rascovsky K, Cosentino S, Grossman M, Elman L, Quinn C, Rosario L, Stark JH, Granit V, Briemberg H, Chenji S, Dionne A, Genge A, Johnston W, Korngut L, Shoesmith C, Zinman L, Kalra S, Benatar M. Defining cognitive impairment in amyotrophic lateral sclerosis: an evaluation of empirical approaches. Amyotroph Lateral Scler Frontotemporal Degener 2022; 23:517-526. [PMID: 35253557 PMCID: PMC9448823 DOI: 10.1080/21678421.2022.2039713] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/17/2022] [Accepted: 01/30/2022] [Indexed: 11/01/2022]
Abstract
Objective: Amyotrophic lateral sclerosis (ALS) is a multi-system disorder characterized primarily by motor neuron degeneration, but may be accompanied by cognitive dysfunction. Statistically appropriate criteria for establishing cognitive impairment (CI) in ALS are lacking. We evaluate quantile regression (QR), that accounts for age and education, relative to a traditional two standard deviation (SD) cutoff for defining CI. Methods: QR of cross-sectional data from a multi-center North American Control (NAC) cohort of 269 healthy adults was used to model the 5th percentile of cognitive scores on the Edinburgh Cognitive and Behavioral ALS Screen (ECAS). The QR approach was compared to traditional two SD cutoff approach using the same NAC cohort (2SD-NAC) and to existing UK-based normative data derived using the 2SD approach (2SD-UK) to assess the impact of cohort selection and statistical model in identifying CI in 182 ALS patients. Results: QR-NAC models revealed that age and education impact cognitive performance on the ECAS. Based on QR-NAC normative cutoffs, the frequency of CI in the 182 PENN ALS patients was 15.9% for ALS specific, 12.6% for ALS nonspecific, and 15.4% for ECAS total. This frequency of CI is substantially more conservative in comparison to the 2SD-UK (20.3%-34.6%) and modestly more conservative to the 2SD-NAC (14.3%-16.5%) approaches for estimating CI. Conclusions: The choice of normative cohort has a substantial impact and choice of statistical method a modest impact on defining CI in ALS. This report establishes normative ECAS thresholds to identify whether ALS patients in the North American population have CI.
Collapse
Affiliation(s)
- Corey T. McMillan
- University of Pennsylvania Perelman School of Medicine, Department of Neurology, Philadelphia, PA, USA
| | - Joanne Wuu
- University of Miami Miller School of Medicine, Department of Neurology, Miami, FL, USA
| | - Katya Rascovsky
- University of Pennsylvania Perelman School of Medicine, Department of Neurology, Philadelphia, PA, USA
| | - Stephanie Cosentino
- Columbia University, The Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, New York, NY, USA
| | - Murray Grossman
- University of Pennsylvania Perelman School of Medicine, Department of Neurology, Philadelphia, PA, USA
| | - Lauren Elman
- University of Pennsylvania Perelman School of Medicine, Department of Neurology, Philadelphia, PA, USA
| | - Colin Quinn
- University of Pennsylvania Perelman School of Medicine, Department of Neurology, Philadelphia, PA, USA
| | - Luis Rosario
- University of Pennsylvania Perelman School of Medicine, Department of Neurology, Philadelphia, PA, USA
| | - Jessica H. Stark
- University of Miami Miller School of Medicine, Department of Neurology, Miami, FL, USA
| | - Volkan Granit
- University of Miami Miller School of Medicine, Department of Neurology, Miami, FL, USA
| | - Hannah Briemberg
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sneha Chenji
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Annie Dionne
- Department of Medicine, Université Laval, Québec, Canada
| | - Angela Genge
- Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada
| | - Wendy Johnston
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Lawrence Korngut
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | | | - Lorne Zinman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | | | - Sanjay Kalra
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Michael Benatar
- University of Miami Miller School of Medicine, Department of Neurology, Miami, FL, USA
| |
Collapse
|
22
|
Albanese A, Ludolph AC, McDermott CJ, Corcia P, Van Damme P, Van den Berg LH, Hardiman O, Rinaldi G, Vanacore N, Dickie B. Tauroursodeoxycholic acid in patients with amyotrophic lateral sclerosis: The TUDCA-ALS trial protocol. Front Neurol 2022; 13:1009113. [PMID: 36237618 PMCID: PMC9552801 DOI: 10.3389/fneur.2022.1009113] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Amyotrophic lateral sclerosis (ALS) is a chronic neurodegenerative rare disease that affects motor neurons in the brain, brainstem, and spinal cord, resulting in progressive weakness and atrophy of voluntary skeletal muscles. Although much has been achieved in understanding the disease pathogenesis, treatment options are limited, and in Europe, riluzole is the only approved drug. Recently, some other drugs showed minor effects. Methods The TUDCA-ALS trial is a phase III, multicenter, randomized, double-blind, placebo-controlled, parallel-group clinical trial. The study aims to enroll 320 patients in 25 centers across seven countries in Europe. Enrolled patients are randomized to one of two treatment arms: TUDCA or identical placebo by oral route. The study measures disease progression during the treatment period and compares it to natural progression during a no-treatment run-in phase. Clinical data and specific biomarkers are measured during the trial. The study is coordinated by a consortium composed of leading European ALS centers. Conclusion This trial is aimed to determine whether TUDCA has a disease-modifying activity in ALS. Demonstration of TUDCA efficacy, combined with the validation of new biomarkers, could advance ALS patient care. Clinical trial registration ClinicalTrials.gov, identifier: NCT03800524.
Collapse
Affiliation(s)
- Alberto Albanese
- Neurology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy,*Correspondence: Alberto Albanese
| | - Albert Christian Ludolph
- Neurology Department, University of Ulm, Ulm, Germany,German Centre of Neurodegenerative Diseases, Site Ulm, Ulm, Germany
| | - Christopher J. McDermott
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Philippe Corcia
- Centre de Référence Maladie Rare (CRMR) SLA et les autres maladies du neurone moteur (FILSLAN), Tours, France,CHU Bretonneau, Tours, France,Federation des CRMR-SLA Tours-Limoges, LITORALS, Tours, France,INSERM U1253, “iBrain,” Université François-Rabelais de Tours, Faculté de Médecine, Tours, France
| | - Philip Van Damme
- Neurology Department, University Hospitals Leuven and Neuroscience Department, KU Leuven, Leuven, Belgium
| | - Leonard H. Van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Orla Hardiman
- Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Dublin, Ireland,Clinical Research Centre, Beaumont Hospital, Dublin, Ireland
| | | | - Nicola Vanacore
- National Centre for Disease Prevention and Health Promotion, National Institute of Health, Rome, Italy
| | - Brian Dickie
- Motor Neurone Disease Association, Northampton, United Kingdom
| | | |
Collapse
|
23
|
Behler A, Lulé D, Ludolph AC, Kassubek J, Müller HP. Longitudinal monitoring of amyotrophic lateral sclerosis by diffusion tensor imaging: Power calculations for group studies. Front Neurosci 2022; 16:929151. [PMID: 36117627 PMCID: PMC9479493 DOI: 10.3389/fnins.2022.929151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Diffusion tensor imaging (DTI) can be used to map disease progression in amyotrophic lateral sclerosis (ALS) and therefore is a promising candidate for a biomarker in ALS. To this end, longitudinal study protocols need to be optimized and validated regarding group sizes and time intervals between visits. The objective of this study was to assess the influences of sample size, the schedule of follow-up measurements, and measurement uncertainties on the statistical power to optimize longitudinal DTI study protocols in ALS. Patients and methods To estimate the measurement uncertainty of a tract-of–interest-based DTI approach, longitudinal test-retest measurements were applied first to a normal data set. Then, DTI data sets of 80 patients with ALS and 50 healthy participants were analyzed in the simulation of longitudinal trajectories, that is, longitudinal fractional anisotropy (FA) values for follow-up sessions were simulated for synthetic patient and control groups with different rates of FA decrease in the corticospinal tract. Monte Carlo simulations of synthetic longitudinal study groups were used to estimate the statistical power and thus the potentially needed sample sizes for a various number of scans at one visit, different time intervals between baseline and follow-up measurements, and measurement uncertainties. Results From the simulation for different longitudinal FA decrease rates, it was found that two scans per session increased the statistical power in the investigated settings unless sample sizes were sufficiently large and time intervals were appropriately long. The positive effect of a second scan per session on the statistical power was particularly pronounced for FA values with high measurement uncertainty, for which the third scan per session increased the statistical power even further. Conclusion With more than one scan per session, the statistical power of longitudinal DTI studies can be increased in patients with ALS. Consequently, sufficient statistical power can be achieved even with limited sample sizes. An improved longitudinal DTI study protocol contributes to the detection of small changes in diffusion metrics and thereby supports DTI as an applicable and reliable non-invasive biomarker in ALS.
Collapse
Affiliation(s)
- Anna Behler
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Dorothée Lulé
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Albert C Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Ulm, Germany
| | - Jan Kassubek
- Department of Neurology, University of Ulm, Ulm, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Ulm, Germany
| | | |
Collapse
|
24
|
Cheung K, Mitsumoto H. Evaluating Personalized (N-of-1) Trials in Rare Diseases: How Much Experimentation Is Enough? HARVARD DATA SCIENCE REVIEW 2022; 2022:10.1162/99608f92.e11adff0. [PMID: 38283317 PMCID: PMC10813653 DOI: 10.1162/99608f92.e11adff0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
For rare diseases, conducting large, randomized trials of new treatments can be infeasible due to limited sample size, and it may answer the wrong scientific questions due to heterogeneity of treatment effects. Personalized (N-of-1) trials are multi-period crossover studies that aim to estimate individual treatment effects, thereby identifying the optimal treatments for individuals. This article examines the statistical design issues of evaluating a personalized (N-of-1) treatment program in people with amyotrophic lateral sclerosis (ALS). We propose an evaluation framework based on an analytical model for longitudinal data observed in a personalized trial. Under this framework, we address two design parameters: length of experimentation in each trial and number of trials needed. For the former, we consider patient-centric design criteria that aim to maximize the benefits of enrolled patients. Using theoretical investigation and numerical studies, we demonstrate that, from a patient's perspective, the duration of an experimentation period should be no longer than one-third of the entire follow-up period of the trial. For the latter, we provide analytical formulae to calculate the power for testing quality improvement due to personalized trials in a randomized evaluation program and hence determine the required number of trials needed for the program. We apply our theoretical results to design an evaluation program for ALS treatments informed by pilot data and show that the length of experimentation has a small impact on power relative to other factors such as the degree of heterogeneity of treatment effects.
Collapse
Affiliation(s)
- Ken Cheung
- Mailman School of Public Health, Columbia University, New York City, New York, United States of America
| | - Hiroshi Mitsumoto
- Columbia University Irving Medical Center, Columbia University, New York City, New York, United States of America
| |
Collapse
|
25
|
Chaytow H, Carroll E, Gordon D, Huang YT, van der Hoorn D, Smith HL, Becker T, Becker CG, Faller KME, Talbot K, Gillingwater TH. Targeting phosphoglycerate kinase 1 with terazosin improves motor neuron phenotypes in multiple models of amyotrophic lateral sclerosis. EBioMedicine 2022; 83:104202. [PMID: 35963713 PMCID: PMC9482929 DOI: 10.1016/j.ebiom.2022.104202] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/01/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder with heterogeneous aetiology and a complex genetic background. Effective therapies are therefore likely to act on convergent pathways such as dysregulated energy metabolism, linked to multiple neurodegenerative diseases including ALS. METHODS Activity of the glycolysis enzyme phosphoglycerate kinase 1 (PGK1) was increased genetically or pharmacologically using terazosin in zebrafish, mouse and ESC-derived motor neuron models of ALS. Multiple disease phenotypes were assessed to determine the therapeutic potential of this approach, including axon growth and motor behaviour, survival and cell death following oxidative stress. FINDINGS We have found that targeting a single bioenergetic protein, PGK1, modulates motor neuron vulnerability in vivo. In zebrafish models of ALS, overexpression of PGK1 rescued motor axon phenotypes and improved motor behaviour. Treatment with terazosin, an FDA-approved compound with a known non-canonical action of increasing PGK1 activity, also improved these phenotypes. Terazosin treatment extended survival, improved motor phenotypes and increased motor neuron number in Thy1-hTDP-43 mice. In ESC-derived motor neurons expressing TDP-43M337V, terazosin protected against oxidative stress-induced cell death and increased basal glycolysis rates, while rescuing stress granule assembly. INTERPRETATION Our data demonstrate that terazosin protects motor neurons via multiple pathways, including upregulating glycolysis and rescuing stress granule formation. Repurposing terazosin therefore has the potential to increase the limited therapeutic options across all forms of ALS, irrespective of disease cause. FUNDING This work was supported by project grant funding from MND Scotland, the My Name'5 Doddie Foundation, Medical Research Council Doctoral Student Training Fellowship [Ref: BST0010Z] and Academy of Medical Sciences grant [SGL023\1100].
Collapse
Affiliation(s)
- Helena Chaytow
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh; Edinburgh, UK; Euan MacDonald Centre for Motor Neuron Disease Research; Edinburgh, UK
| | - Emily Carroll
- Nuffield Department of Clinical Neurosciences, University of Oxford; Oxford, UK
| | - David Gordon
- Nuffield Department of Clinical Neurosciences, University of Oxford; Oxford, UK
| | - Yu-Ting Huang
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh; Edinburgh, UK; Euan MacDonald Centre for Motor Neuron Disease Research; Edinburgh, UK
| | - Dinja van der Hoorn
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh; Edinburgh, UK; Euan MacDonald Centre for Motor Neuron Disease Research; Edinburgh, UK
| | - Hannah Louise Smith
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh; Edinburgh, UK; Euan MacDonald Centre for Motor Neuron Disease Research; Edinburgh, UK
| | - Thomas Becker
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh; Edinburgh, UK; Euan MacDonald Centre for Motor Neuron Disease Research; Edinburgh, UK; Center for Regenerative Therapies at the TU Dresden, Technische Universität Dresden, Dresden, Germany
| | - Catherina Gwynne Becker
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh; Edinburgh, UK; Euan MacDonald Centre for Motor Neuron Disease Research; Edinburgh, UK; Center for Regenerative Therapies at the TU Dresden, Technische Universität Dresden, Dresden, Germany
| | | | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford; Oxford, UK
| | - Thomas Henry Gillingwater
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh; Edinburgh, UK; Euan MacDonald Centre for Motor Neuron Disease Research; Edinburgh, UK.
| |
Collapse
|
26
|
Wong C, Dakin RS, Williamson J, Newton J, Steven M, Colville S, Stavrou M, Gregory JM, Elliott E, Mehta AR, Chataway J, Swingler RJ, Parker RA, Weir CJ, Stallard N, Parmar MKB, Macleod MR, Pal S, Chandran S. Motor Neuron Disease Systematic Multi-Arm Adaptive Randomised Trial (MND-SMART): a multi-arm, multi-stage, adaptive, platform, phase III randomised, double-blind, placebo-controlled trial of repurposed drugs in motor neuron disease. BMJ Open 2022; 12:e064173. [PMID: 35798516 PMCID: PMC9263927 DOI: 10.1136/bmjopen-2022-064173] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Motor neuron disease (MND) is a rapidly fatal neurodegenerative disease. Despite decades of research and clinical trials there remains no cure and only one globally approved drug, riluzole, which prolongs survival by 2-3 months. Recent improved mechanistic understanding of MND heralds a new translational era with many potential targets being identified that are ripe for clinical trials. Motor Neuron Disease Systematic Multi-Arm Adaptive Randomised Trial (MND-SMART) aims to evaluate the efficacy of drugs efficiently and definitively in a multi-arm, multi-stage, adaptive trial. The first two drugs selected for evaluation in MND-SMART are trazodone and memantine. METHODS AND ANALYSIS Initially, up to 531 participants (177/arm) will be randomised 1:1:1 to oral liquid trazodone, memantine and placebo. The coprimary outcome measures are the Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALSFRS-R) and survival. Comparisons will be conducted in four stages. The decision to continue randomising to arms after each stage will be made by the Trial Steering Committee who receive recommendations from the Independent Data Monitoring Committee. The primary analysis of ALSFRS-R will be conducted when 150 participants/arm, excluding long survivors, have completed 18 months of treatment; if positive the survival effect will be inferentially analysed when 113 deaths have been observed in the placebo group. The trial design ensures that other promising drugs can be added for evaluation in planned trial adaptations. Using this novel trial design reduces time, cost and number of participants required to definitively (phase III) evaluate drugs and reduces exposure of participants to potentially ineffective treatments. ETHICS AND DISSEMINATION MND-SMART was approved by the West of Scotland Research Ethics Committee on 2 October 2019. (REC reference: 19/WS/0123) Results of the study will be submitted for publication in a peer-reviewed journal and a summary provided to participants. TRIAL REGISTRATION NUMBERS European Clinical Trials Registry (2019-000099-41); NCT04302870.
Collapse
Affiliation(s)
- Charis Wong
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Rachel S Dakin
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Jill Williamson
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Judith Newton
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Michelle Steven
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Shuna Colville
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Maria Stavrou
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Jenna M Gregory
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Elizabeth Elliott
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Arpan R Mehta
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Robert J Swingler
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- London North West University Healthcare NHS Trust, Northwick Park Hospital, London, UK
| | - Richard Anthony Parker
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Malcolm R Macleod
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Suvankar Pal
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Siddharthan Chandran
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
27
|
Malhotra HS, Singh BP, Kumar N, Garg RK, Kirubakaran R, Emsley HCA, Chhetri SK, Mulvaney CA, Villanueva G. Immunomodulatory treatment for amyotrophic lateral sclerosis/motor neuron disease. Hippokratia 2022. [DOI: 10.1002/14651858.cd013945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Hardeep S Malhotra
- Department of Neurology; King George's Medical University; Lucknow India
- Cochrane India-King George's Medical University, Lucknow affiliate; Lucknow India
| | - Balendra P Singh
- Cochrane India-King George's Medical University, Lucknow affiliate; Lucknow India
- Department of Prosthodontics; King George's Medical University; Lucknow India
| | - Neeraj Kumar
- Department of Neurology; King George's Medical University; Lucknow India
- Cochrane India-King George's Medical University, Lucknow affiliate; Lucknow India
| | - Ravindra K Garg
- Department of Neurology; King George's Medical University; Lucknow India
| | - Richard Kirubakaran
- Cochrane India-CMC Vellore Affiliate, Prof. BV Moses Centre for Evidence Informed Healthcare and Health Policy; Christian Medical College; Vellore India
| | - Hedley CA Emsley
- Department of Neurology; Lancashire Teaching Hospitals NHS Foundation Trust; Preston UK
- Lancaster Medical School; Lancaster University; Lancaster UK
| | - Suresh Kumar Chhetri
- Department of Neurology; Lancashire Teaching Hospitals NHS Foundation Trust; Preston UK
- Lancaster Medical School; Lancaster University; Lancaster UK
| | | | | |
Collapse
|
28
|
Hayden CD, Murphy BP, Hardiman O, Murray D. Measurement of upper limb function in ALS: a structure review of current methods and future directions. J Neurol 2022; 269:4089-4101. [PMID: 35612658 PMCID: PMC9293830 DOI: 10.1007/s00415-022-11179-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
Measurement of upper limb function is critical for tracking clinical severity in amyotrophic lateral sclerosis (ALS). The Amyotrophic Lateral Sclerosis Rating Scale-revised (ALSFRS-r) is the primary outcome measure utilised in clinical trials and research in ALS. This scale is limited by floor and ceiling effects within subscales, such that clinically meaningful changes for subjects are often missed, impacting upon the evaluation of new drugs and treatments. Technology has the potential to provide sensitive, objective outcome measurement. This paper is a structured review of current methods and future trends in the measurement of upper limb function with a particular focus on ALS. Technologies that have the potential to radically change the upper limb measurement field and explore the limitations of current technological sensors and solutions in terms of costs and user suitability are discussed. The field is expanding but there remains an unmet need for simple, sensitive and clinically meaningful tests of upper limb function in ALS along with identifying consensus on the direction technology must take to meet this need.
Collapse
Affiliation(s)
- C D Hayden
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland. .,Department of Mechanical, Manufacturing and Biomedical Engineering, Trinity College Dublin, Dublin 2, Ireland. .,Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse St, Dublin 2, D02 R590, Ireland.
| | - B P Murphy
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland.,Department of Mechanical, Manufacturing and Biomedical Engineering, Trinity College Dublin, Dublin 2, Ireland.,Advanced Materials and Bioengineering Research Centre (AMBER), Trinity College Dublin, Dublin 2, Ireland
| | - O Hardiman
- Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse St, Dublin 2, D02 R590, Ireland.,Neurocent Directorate, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - D Murray
- Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse St, Dublin 2, D02 R590, Ireland.,Neurocent Directorate, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| |
Collapse
|
29
|
Goutman SA, Hardiman O, Al-Chalabi A, Chió A, Savelieff MG, Kiernan MC, Feldman EL. Recent advances in the diagnosis and prognosis of amyotrophic lateral sclerosis. Lancet Neurol 2022; 21:480-493. [PMID: 35334233 PMCID: PMC9513753 DOI: 10.1016/s1474-4422(21)00465-8] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/24/2021] [Accepted: 12/16/2021] [Indexed: 12/14/2022]
Abstract
The diagnosis of amyotrophic lateral sclerosis can be challenging due to its heterogeneity in clinical presentation and overlap with other neurological disorders. Diagnosis early in the disease course can improve outcomes as timely interventions can slow disease progression. An evolving awareness of disease genotypes and phenotypes and new diagnostic criteria, such as the recent Gold Coast criteria, could expedite diagnosis. Improved prognosis, such as that achieved with the survival model from the European Network for the Cure of ALS, could inform the patient and their family about disease course and improve end-of-life planning. Novel staging and scoring systems can help monitor disease progression and might potentially serve as clinical trial outcomes. Lastly, new tools, such as fluid biomarkers, imaging modalities, and neuromuscular electrophysiological measurements, might increase diagnostic and prognostic accuracy.
Collapse
Affiliation(s)
| | - Orla Hardiman
- Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, and Department of Neurology, King's College London, London, UK
| | - Adriano Chió
- Rita Levi Montalcini Department of Neurosciences, University of Turin, Turin, Italy
| | | | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia; Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
30
|
Ahmed N, Baker MR, Bashford J. The landscape of neurophysiological outcome measures in ALS interventional trials: A systematic review. Clin Neurophysiol 2022; 137:132-141. [PMID: 35313253 PMCID: PMC10166714 DOI: 10.1016/j.clinph.2022.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We collated all interventional clinical trials in amyotrophic lateral sclerosis (ALS), which utilised at least one neurophysiological technique as a primary or secondary outcome measure. By identifying the strengths and limitations of these studies, we aim to guide study design in future trials. METHODS We conducted and reported this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight databases were searched from inception. In total, 703 studies were retrieved for screening and eligibility assessment. RESULTS Dating back to 1986, 32 eligible interventional clinical trials were identified, recruiting a median of 30 patients per completed trial. The most widely employed neurophysiological techniques were electromyography, motor unit number estimation (including motor unit number index), neurophysiological index and transcranial magnetic stimulation (including resting motor threshold and short-interval intracortical inhibition). Almost 40% of trials reported a positive outcome with respect to at least one neurophysiological measure. The interventions targeted either ion channels, immune mechanisms or neuronal metabolic pathways. CONCLUSIONS Neurophysiology offers many promising biomarkers that can be utilised as outcome measures in interventional clinical trials in ALS. When selecting the most appropriate technique, key considerations include methodological standardisation, target engagement and logistical burden. SIGNIFICANCE Future trial design in ALS would benefit from a standardised, updated and easily accessible repository of neurophysiological outcome measures.
Collapse
Affiliation(s)
- N Ahmed
- GKT School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, UK
| | - M R Baker
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - J Bashford
- UK Dementia Research Institute, Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
| |
Collapse
|
31
|
Tornese P, Lalli S, Cocco A, Albanese A. Review of disease-modifying drug trials in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:521-529. [PMID: 35228271 DOI: 10.1136/jnnp-2021-328470] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/26/2022] [Indexed: 01/22/2023]
Abstract
We analysed clinical trials of pharmacological interventions on patients with amyotrophic lateral sclerosis (ALS), and compared study quality and design features. The systematic review included articles published in PubMed and trials registered in ClinicalTrials.gov. Included studies were randomised double-blind placebo-controlled clinical trials assessing a disease-modifying pharmacological intervention. Studies were excluded if primary end points were safety or dose finding. A total of 28 735 articles and 721 current trials were identified. 76 published articles and 23 ongoing trials met inclusion criteria; they referred to distinct populations comprising 22 817 participants with ALS. Most articles and all current trials had parallel group design; few articles had cross-over design. A run-in observation period was included in about 20% of published studies and ongoing trials. Primary end points included functional assessment, survival, muscle strength, respiratory function, biomarkers and composite measures. Most recent trials had only functional assessment and survival. Risk of bias was high in 23 articles, moderate in 35, low in 18. A disease modification effect was observed for 10 interventions in phase II studies, two of which were confirmed in phase III. Three confirmatory phase III studies are currently underway. The present review provides cues for the design of future trials. Functional decline and survival, as single or composite measures, stand as the reference end points. Post hoc analyses should not be performed, particularly in studies using composite end points. There is a general agreement on diagnostic criteria; but eligibility criteria must be improved. Run-in observations may be used for censoring patients but are discouraged for refining participants' eligibility. The ALS Functional Rating Scale-Revised needs improvement for use as an ordinal measure of functional decline.
Collapse
Affiliation(s)
- Paolo Tornese
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Stefania Lalli
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Antoniangela Cocco
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Alberto Albanese
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Italy .,Department of Neuroscience, Catholic University, Milan, Italy
| |
Collapse
|
32
|
Dreger M, Steinbach R, Otto M, Turner MR, Grosskreutz J. Cerebrospinal fluid biomarkers of disease activity and progression in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:422-435. [PMID: 35105727 PMCID: PMC8921583 DOI: 10.1136/jnnp-2021-327503] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/29/2021] [Indexed: 12/04/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a relentlessly progressive neurodegenerative disease, and only modest disease-modifying strategies have been established to date. Numerous clinical trials have been conducted in the past years, but have been severely hampered by the wide-ranging heterogeneity of both the biological origins and clinical characteristics of the disease. Thus, reliable biomarkers of disease activity are urgently needed to stratify patients into homogenous groups with aligned disease trajectories to allow a more effective design of clinical trial. In this review, the most promising candidate biomarkers in the cerebrospinal fluid (CSF) of patients with ALS will be summarised. Correlations between biomarker levels and clinical outcome parameters are discussed, while highlighting potential pitfalls and intercorrelations of these clinical parameters. Several CSF molecules have shown potential as biomarkers of progression and prognosis, but large, international, multicentric and longitudinal studies are crucial for validation. A more standardised choice of clinical endpoints in these studies, as well as the application of individualised models of clinical progression, would allow the quantification of disease trajectories, thereby allowing a more accurate analysis of the clinical implications of candidate biomarkers. Additionally, a comparative analysis of several biomarkers and ideally the application of a multivariate analysis including comprehensive genotypic, phenotypic and clinical characteristics collectively contributing to biomarker levels in the CSF, could promote their verification. Thus, reliable prognostic markers and markers of disease activity may improve clinical trial design and patient management in the direction of precision medicine.
Collapse
Affiliation(s)
- Marie Dreger
- Department of Neurology, Jena University Hospital, Jena, Thüringen, Germany
| | - Robert Steinbach
- Department of Neurology, Jena University Hospital, Jena, Thüringen, Germany
| | - Markus Otto
- Department of Neurology, University of Halle (Saale), Halle (Saale), Germany
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, Oxfordshire, UK
| | - Julian Grosskreutz
- Precision Neurology, Department of Neurology, University of Luebeck Human Medicine, Luebeck, Schleswig-Holstein, Germany
| |
Collapse
|
33
|
van Eijk RP, Roes KC, de Greef‐van der Sandt I, van den Berg LH, Lu Y. Functional loss and mortality in randomized clinical trials for amyotrophic lateral sclerosis: to combine, or not to combine – that is the estimand. Clin Pharmacol Ther 2022; 111:817-825. [PMID: 35076930 PMCID: PMC8940672 DOI: 10.1002/cpt.2533] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/15/2022] [Indexed: 11/07/2022]
Abstract
Amyotrophic lateral sclerosis is a rapidly progressive disease leading to death in, on average, 3–5 years after first symptom onset. Consequently, there are frequently a non‐negligible number of patients who die during the course of a clinical trial. This introduces bias in end points such as daily functioning, muscle strength, and quality of life. In this paper, we outline how the choice of strategy to handle death affects the interpretation of the trial results. We provide a general overview of the considerations, positioned in the estimand framework, and discuss the possibility that not every strategy provides a clinically relevant answer in each setting. The relevance of a strategy changes as a function of the intended trial duration, hypothesized treatment effect, and population included. It is important to consider this trade‐off at the design stage of a clinical trial, as this will clarify the exact research question that is being answered, and better guide the planning, design, and analysis of the study.
Collapse
Affiliation(s)
- Ruben P.A. van Eijk
- Department of Biomedical Data Science and Center for Innovative Study Design School of Medicine Stanford University Stanford United States
- Department of Neurology UMC Utrecht Brain Centre University Medical Centre Utrecht Utrecht the Netherlands
| | - Kit C.B. Roes
- Department of Health Evidence Radboud Medical Centre Nijmegen Section Biostatistics the Netherlands
| | | | - Leonard H. van den Berg
- Department of Neurology UMC Utrecht Brain Centre University Medical Centre Utrecht Utrecht the Netherlands
| | - Ying Lu
- Department of Biomedical Data Science and Center for Innovative Study Design School of Medicine Stanford University Stanford United States
| |
Collapse
|
34
|
Staats KA, Borchelt DR, Tansey MG, Wymer J. Blood-based biomarkers of inflammation in amyotrophic lateral sclerosis. Mol Neurodegener 2022; 17:11. [PMID: 35073950 PMCID: PMC8785449 DOI: 10.1186/s13024-022-00515-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 12/30/2021] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is a devastating neurodegenerative disease in which many processes are detected including (neuro)inflammation. Many drugs have been tested for ALS in clinical trials but most have failed to reach their primary endpoints. The development and inclusion of different types of biomarkers in diagnosis and clinical trials can assist in determining target engagement of a drug, in distinguishing between ALS and other diseases, and in predicting disease progression rate, drug responsiveness, or an adverse event. Ideally, among other characteristics, a biomarker in ALS correlates highly with a disease process in the central nervous system or with disease progression and is conveniently obtained in a peripheral tissue. Here, we describe the state of biomarkers of inflammation in ALS by focusing on peripherally detectable and cellular responses from blood cells, and provide new (combinatorial) directions for exploration that are now feasible due to technological advancements.
Collapse
Affiliation(s)
- Kim A. Staats
- Staats Life Sciences Consulting, LLC, Los Angeles, CA USA
| | - David R. Borchelt
- Department of Neuroscience, University of Florida College of Medicine, McKnight Brain Institute, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, Florida USA
| | - Malú Gámez Tansey
- Department of Neuroscience and Center for Translational Research in Neurodegenerative Disease at The University of Florida College of Medicine, Gainesville, Florida USA
| | - James Wymer
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida USA
| |
Collapse
|
35
|
Beswick E, Forbes D, Hassan Z, Wong C, Newton J, Carson A, Abrahams S, Chandran S, Pal S. A systematic review of non-motor symptom evaluation in clinical trials for amyotrophic lateral sclerosis. J Neurol 2022; 269:411-426. [PMID: 34120226 PMCID: PMC8738361 DOI: 10.1007/s00415-021-10651-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is increasingly recognised as a multi-system disorder, presenting with common and impactful non-motor symptoms, such as neuropsychiatric symtpoms, cognitive and behavioural changes, pain, disordered sleep, fatigue and problematic saliva. AIM/HYPOTHESIS We aimed to systematically review 25 years of ALS clinical trials data to identify if non-motor features were evaluated, in addition to the traditional measures of motor functioning and survival, and where evaluated to describe the instruments used to assess. We hypothesised that assessment of non-motor symptoms has been largely neglected in trial design and not evaluated with ALS-suitable instruments. METHODS We reviewed clinical trials of investigative medicinal products in ALS, since the licensing of riluzole in 1994. Trial registry databases including WHO International Trials Registry, European Clinical Trials Register, clinicaltrials.gov, and PubMed were systematically searched for Phase II, III or IV trials registered, completed or published between 01/01/1994 and 16/09/2020. No language restrictions were applied. RESULTS 237 clinical trials, including over 29,222 participants, were investigated for their use of non-motor outcome measures. These trials evaluated neuropsychiatric symptoms (75, 32%), cognitive impairment (16, 6.8%), behavioural change (34, 14%), pain (55, 23%), sleep disturbances (12, 5%) and fatigue (18, 8%). Problematic saliva was assessed as part of composite ALS-FRS(R) scores in 184 trials (78%) but with no focus on this as an isolated symptom. 31 (13%) trials including 3585 participants did not include any assessment of non-motor symptoms. CONCLUSIONS Non-motor symptoms such as neuropsychiatric, cognitive and behavioural changes, pain, disordered sleep, fatigue, and problematic saliva have not been consistently evaluated in trials for people with ALS. Where evaluated, non-symptoms were primarily assessed using instruments and impairment thresholds that are not adapted for people with ALS. Future trials should include non-motor symptom assessments to evaluate the additional potential therapeutic benefit of candidate drugs. PROPSERO REGISTRATION CRD42020223648.
Collapse
Affiliation(s)
- Emily Beswick
- grid.4305.20000 0004 1936 7988Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB Scotland, UK ,grid.4305.20000 0004 1936 7988Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Deborah Forbes
- grid.4305.20000 0004 1936 7988Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB Scotland, UK ,grid.4305.20000 0004 1936 7988Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Zack Hassan
- grid.4305.20000 0004 1936 7988Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB Scotland, UK ,grid.4305.20000 0004 1936 7988Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Charis Wong
- grid.4305.20000 0004 1936 7988Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB Scotland, UK ,grid.4305.20000 0004 1936 7988Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Judith Newton
- grid.4305.20000 0004 1936 7988Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB Scotland, UK ,grid.4305.20000 0004 1936 7988Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Alan Carson
- grid.4305.20000 0004 1936 7988Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Sharon Abrahams
- grid.4305.20000 0004 1936 7988Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988Human Cognitive Neurosciences, Psychology, School of Philosophy, Psychology and Language Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Siddharthan Chandran
- grid.4305.20000 0004 1936 7988Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB Scotland, UK ,grid.4305.20000 0004 1936 7988Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988Human Cognitive Neurosciences, Psychology, School of Philosophy, Psychology and Language Sciences, The University of Edinburgh, Edinburgh, Scotland, UK ,grid.4305.20000 0004 1936 7988UK Dementia Research Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Suvankar Pal
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK. .,Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4 SB, Scotland, UK. .,Euan MacDonald Centre for MND Research, The University of Edinburgh, Edinburgh, Scotland, UK.
| |
Collapse
|
36
|
Zakharova MN, Abramova AA. Lower and upper motor neuron involvement and their impact on disease prognosis in amyotrophic lateral sclerosis. Neural Regen Res 2022; 17:65-73. [PMID: 34100429 PMCID: PMC8451581 DOI: 10.4103/1673-5374.314289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Amyotrophic lateral sclerosis is a fatal neurodegenerative disease characterized by progressive muscle wasting, breathing and swallowing difficulties resulting in patient’s death in two to five years after disease onset. In amyotrophic lateral sclerosis, both upper and lower motor neurons of the corticospinal tracts are involved in the process of neurodegeneration, accounting for great clinical heterogeneity of the disease. Clinical phenotype has great impact on the pattern and rate of amyotrophic lateral sclerosis progression and overall survival prognosis. Creating more homogenous patient groups in order to study the effects of drug agents on specific manifestations of the disease is a challenging issue in amyotrophic lateral sclerosis clinical trials. Since amyotrophic lateral sclerosis has low incidence rates, conduction of multicenter trials requires certain standardized approaches to disease diagnosis and staging. This review focuses on the current approaches in amyotrophic lateral sclerosis classification and staging system based on clinical examination and additional instrumental methods, highlighting the role of upper and lower motor neuron involvement in different phenotypes of the disease. We demonstrate that both clinical and instrumental findings can be useful in evaluating severity of upper motor neuron and lower motor neuron involvement and predicting the following course of the disease. Addressing disease heterogeneity in amyotrophic lateral sclerosis clinical trials could lead to study designs that will assess drug efficacy in specific patient groups, based on the disease pathophysiology and spatiotemporal pattern. Although clinical evaluation can be a sufficient screening method for dividing amyotrophic lateral sclerosis patients into clinical subgroups, we provide proof that instrumental studies could provide valuable insights in the disease pathology.
Collapse
|
37
|
Thompson AG, Gray E, Verber N, Bobeva Y, Lombardi V, Shepheard SR, Yildiz O, Feneberg E, Farrimond L, Dharmadasa T, Gray P, Edmond EC, Scaber J, Gagliardi D, Kirby J, Jenkins TM, Fratta P, McDermott CJ, Manohar SG, Talbot K, Malaspina A, Shaw PJ, Turner MR. OUP accepted manuscript. Brain Commun 2022; 4:fcac029. [PMID: 35224491 PMCID: PMC8870425 DOI: 10.1093/braincomms/fcac029] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 11/25/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
The routine clinical integration of individualized objective markers of disease activity in those diagnosed with the neurodegenerative disorder amyotrophic lateral sclerosis is a key requirement for therapeutic development. A large, multicentre, clinic-based, longitudinal cohort was used to systematically appraise the leading candidate biofluid biomarkers in the stratification and potential therapeutic assessment of those with amyotrophic lateral sclerosis. Incident patients diagnosed with amyotrophic lateral sclerosis (n = 258), other neurological diseases (n = 80) and healthy control participants (n = 101), were recruited and followed at intervals of 3–6 months for up to 30 months. Cerebrospinal fluid neurofilament light chain and chitotriosidase 1 and blood neurofilament light chain, creatine kinase, ferritin, complement C3 and C4 and C-reactive protein were measured. Blood neurofilament light chain, creatine kinase, serum ferritin, C3 and cerebrospinal fluid neurofilament light chain and chitotriosidase 1 were all significantly elevated in amyotrophic lateral sclerosis patients. First-visit plasma neurofilament light chain level was additionally strongly associated with survival (hazard ratio for one standard deviation increase in log10 plasma neurofilament light chain 2.99, 95% confidence interval 1.65–5.41, P = 0.016) and rate of disability progression, independent of other prognostic factors. A small increase in level was noted within the first 12 months after reported symptom onset (slope 0.031 log10 units per month, 95% confidence interval 0.012–0.049, P = 0.006). Modelling the inclusion of plasma neurofilament light chain as a therapeutic trial outcome measure demonstrated that a significant reduction in sample size and earlier detection of disease-slowing is possible, compared with using the revised Amyotrophic Lateral Sclerosis Functional Rating Scale. This study provides strong evidence that blood neurofilament light chain levels outperform conventional measures of disease activity at the group level. The application of blood neurofilament light chain has the potential to radically reduce the duration and cost of therapeutic trials. It might also offer a first step towards the goal of more personalized objective disease activity monitoring for those living with amyotrophic lateral sclerosis.
Collapse
Affiliation(s)
| | - Elizabeth Gray
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Nick Verber
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Yoana Bobeva
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Stephanie R. Shepheard
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Ozlem Yildiz
- Blizard Institute, Queen Mary University of London, London, UK
| | - Emily Feneberg
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lucy Farrimond
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Thanuja Dharmadasa
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Pamela Gray
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Evan C. Edmond
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Jakub Scaber
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Delia Gagliardi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Janine Kirby
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Thomas M. Jenkins
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Pietro Fratta
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Sanjay G. Manohar
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Andrea Malaspina
- Blizard Institute, Queen Mary University of London, London, UK
- Correspondence may also be addressed to: Prof Andrea Malaspina Blizard Institute 4 Newark St, Whitechapel London, E1 2AT, UK E-mail:
| | - Pamela J. Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- Correspondence may also be addressed to: Prof Dame Pamela Shaw Sheffield Institute for Translational Neuroscience (SITraN) University of Sheffield, 385a Glossop Rd Broomhall, Sheffield, S10 2HQ, UK E-mail:
| | - Martin R. Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Correspondence to: Prof Martin Turner Nuffield Department of Clinical Neurosciences Level 6, West Wing, John Radcliffe Hospital Oxford, OX3 9DU, UK E-mail:
| |
Collapse
|
38
|
Wong C, Stavrou M, Elliott E, Gregory JM, Leigh N, Pinto AA, Williams TL, Chataway J, Swingler R, Parmar MKB, Stallard N, Weir CJ, Parker RA, Chaouch A, Hamdalla H, Ealing J, Gorrie G, Morrison I, Duncan C, Connelly P, Carod-Artal FJ, Davenport R, Reitboeck PG, Radunovic A, Srinivasan V, Preston J, Mehta AR, Leighton D, Glasmacher S, Beswick E, Williamson J, Stenson A, Weaver C, Newton J, Lyle D, Dakin R, Macleod M, Pal S, Chandran S. Clinical trials in amyotrophic lateral sclerosis: a systematic review and perspective. Brain Commun 2021; 3:fcab242. [PMID: 34901853 PMCID: PMC8659356 DOI: 10.1093/braincomms/fcab242] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 09/07/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022] Open
Abstract
Amyotrophic lateral sclerosis is a progressive and devastating neurodegenerative disease. Despite decades of clinical trials, effective disease-modifying drugs remain scarce. To understand the challenges of trial design and delivery, we performed a systematic review of Phase II, Phase II/III and Phase III amyotrophic lateral sclerosis clinical drug trials on trial registries and PubMed between 2008 and 2019. We identified 125 trials, investigating 76 drugs and recruiting more than 15 000 people with amyotrophic lateral sclerosis. About 90% of trials used traditional fixed designs. The limitations in understanding of disease biology, outcome measures, resources and barriers to trial participation in a rapidly progressive, disabling and heterogenous disease hindered timely and definitive evaluation of drugs in two-arm trials. Innovative trial designs, especially adaptive platform trials may offer significant efficiency gains to this end. We propose a flexible and scalable multi-arm, multi-stage trial platform where opportunities to participate in a clinical trial can become the default for people with amyotrophic lateral sclerosis.
Collapse
Affiliation(s)
- Charis Wong
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Maria Stavrou
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Elizabeth Elliott
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Jenna M Gregory
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Nigel Leigh
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, BN1 9PX, UK
| | - Ashwin A Pinto
- Neurology Department, Wessex Neurosciences Centre, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - Timothy L Williams
- Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London WC1B 5EH, UK.,National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, W1T 7DN, UK.,MRC CTU at UCL, Institute of Clinical Trials and Methodology, University College London, London, WC1V 6LJ, UK
| | - Robert Swingler
- Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Mahesh K B Parmar
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, University College London, London, WC1V 6LJ, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, Level 2, NINE Edinburgh BioQuarter, 9 Little France Road, Edinburgh EH16 4UX, UK
| | - Richard A Parker
- Edinburgh Clinical Trials Unit, Usher Institute, Level 2, NINE Edinburgh BioQuarter, 9 Little France Road, Edinburgh EH16 4UX, UK
| | - Amina Chaouch
- Motor Neurone Disease Care Centre, Manchester Centre for Clinical Neurosciences, Salford, M6 8HD, UK
| | - Hisham Hamdalla
- Motor Neurone Disease Care Centre, Manchester Centre for Clinical Neurosciences, Salford, M6 8HD, UK
| | - John Ealing
- Motor Neurone Disease Care Centre, Manchester Centre for Clinical Neurosciences, Salford, M6 8HD, UK
| | - George Gorrie
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, G51 4TF, UK
| | - Ian Morrison
- Department of Neurology, NHS Tayside, Dundee, DD2 1UB, UK
| | - Callum Duncan
- Department of Neurology, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK
| | - Peter Connelly
- NHS Research Scotland Neuroprogressive Disorders and Dementia Network, Ninewells Hospital, Dundee, DD1 9SY, UK
| | | | - Richard Davenport
- Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, EH16 4SA, UK
| | - Pablo Garcia Reitboeck
- Atkinson Morley Regional Neurosciences Centre, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | | | | | - Jenny Preston
- Department of Neurology, NHS Ayrshire & Arran, KA12 8SS, UK
| | - Arpan R Mehta
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Danielle Leighton
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Stella Glasmacher
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Emily Beswick
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Jill Williamson
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Amy Stenson
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Christine Weaver
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Judith Newton
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Dawn Lyle
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Rachel Dakin
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Suvankar Pal
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| |
Collapse
|
39
|
Sleutjes BTHM, Bystrup Jacobsen A, Tankisi H, Gorkem Sirin N, Emre Oge A, Henderson RD, van Doorn PA, van den Berg LH, van Eijk RPA. Advancing disease monitoring of amyotrophic lateral sclerosis with the compound muscle action potential scan. Clin Neurophysiol 2021; 132:3152-3159. [PMID: 34749234 DOI: 10.1016/j.clinph.2021.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/20/2021] [Accepted: 09/15/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine which compound muscle action potential (CMAP) scan-derived electrophysiological markers are most sensitive for monitoring disease progression in amyotrophic lateral sclerosis (ALS), and whether they hold value for clinical trials. METHODS We used four independent patient cohorts to assess longitudinal patterns of a comprehensive set of electrophysiological markers including their association with the ALS functional rating scale (ALSFRS-R). Results were translated to trial sample size requirements. RESULTS In 65 patients, 225 thenar CMAP scan recordings were obtained. Electrophysiological markers showed extensive variation in their longitudinal trajectories. Expressed as standard deviations per month, motor unit number estimation (MUNE) values declined by 0.09 (CI 0.07-0.12), D50, a measure that quantifies CMAP scan discontinuities, declined by 0.09 (CI 0.06-0.13) and maximum CMAP by 0.05 (CI 0.03-0.08). ALSFRS-R declined fastest (0.12, CI 0.08 - 0.15), however the between-patient variability was larger compared to electrophysiological markers, resulting in larger sample sizes. MUNE reduced the sample size by 19.1% (n = 388 vs n = 314) for a 6-month study compared to the ALSFRS-R. CONCLUSIONS CMAP scan-derived markers show promise in monitoring disease progression in ALS patients, where MUNE may be its most suitable derivate. SIGNIFICANCE MUNE may increase clinical trial efficiency compared to clinical endpoints.
Collapse
Affiliation(s)
- Boudewijn T H M Sleutjes
- Department of Neurology, Brain Centre Utrecht, Utrecht, the Netherlands; Department of Neurology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.
| | | | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - N Gorkem Sirin
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Emre Oge
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Robert D Henderson
- Department of Neurology, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Pieter A van Doorn
- Department of Neurology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Ruben P A van Eijk
- Department of Neurology, Brain Centre Utrecht, Utrecht, the Netherlands; Biostatistics and Research Support, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| |
Collapse
|
40
|
De Marchi F, Collo A, Scognamiglio A, Cavaletto M, Bozzi Cionci N, Biroli G, Di Gioia D, Riso S, Mazzini L. Study protocol on the safety and feasibility of a normocaloric ketogenic diet in people with amyotrophic lateral sclerosis. Nutrition 2021; 94:111525. [PMID: 34864433 DOI: 10.1016/j.nut.2021.111525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/30/2021] [Accepted: 10/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study evaluates the safety and feasibility of a normocaloric ketogenic diet (KD) in people with amyotrophic lateral sclerosis (ALS) for reducing hyperexcitability levels and modulating neuroinflammation. METHODS This is a prospective, open-label pilot study involving men and women diagnosed with ALS, ages 18 to 75 y. The primary outcome is the safety and reproducibility of the KD in people with ALS. We will monitor secondary clinical outcomes with the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale score, forced vital capacity, the Amyotrophic Lateral Sclerosis Assessment Questionnaire, blood parameters, and gut microbiota analyses. All participants will follow the KD for 8 wk. During the diet, the clinical status of all participants will be monitored every 15 d through neurologic and nutritional visits and biochemical markers. The research ethics committee approved the study. RESULTS Safety will be assessed by measuring the number and severity of adverse events, including death, and any changes in blood chemistry, vital signs, and clinical exam results. Tolerability will be assessed to complete the proposed 8 wk of treatment while maintaining adequate nutritional status without inducing malnutrition. CONCLUSIONS Adequate caloric intake is essential in ALS, because insufficient intake induces loss of body mass. We hope that the proposed study will provide a positive result in terms of the safety and feasibility of a KD in people ALS, with the purpose of developing a patient-centered diet program to limit disease progression and possibly improve survival.
Collapse
Affiliation(s)
- Fabiola De Marchi
- Neurology Unit, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy.
| | - Alessandro Collo
- Clinical Nutrition and Dietetic Unit, Maggiore della Carità Hospital, University of Piemonte Orientale, Novara, Italy
| | - Ada Scognamiglio
- Neurology Unit, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Maria Cavaletto
- Department of "Scienze e Innovazione Tecnologica-DiSIT," University of Piemonte Orientale, Vercelli, Italy
| | - Nicole Bozzi Cionci
- Department of Agricultural and Food Sciences, University of Bologna, Bologna, Italy
| | - Giampaolo Biroli
- Clinical Nutrition and Dietetic Unit, Maggiore della Carità Hospital, University of Piemonte Orientale, Novara, Italy
| | - Diana Di Gioia
- Department of Agricultural and Food Sciences, University of Bologna, Bologna, Italy
| | - Sergio Riso
- Clinical Nutrition and Dietetic Unit, Maggiore della Carità Hospital, University of Piemonte Orientale, Novara, Italy
| | - Letizia Mazzini
- Neurology Unit, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| |
Collapse
|
41
|
Murray D, Rooney J, Al-Chalabi A, Bunte T, Chiwera T, Choudhury M, Chio A, Fenton L, Fortune J, Maidment L, Manera U, Mcdermott C, Meldrum D, Meyjes M, Tattersall R, Torrieri MC, Van Damme P, Vanderlinden E, Wood C, Van Den Berg LH, Hardiman O. Correlations between measures of ALS respiratory function: is there an alternative to FVC? Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:495-504. [PMID: 34590504 DOI: 10.1080/21678421.2021.1908362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: An ongoing longitudinal study in six European sites includes a 3-monthly assessment of forced vital capacity (FVC), slow vital capacity (SVC), peak cough flow (PCF), and Sniff nasal inspiratory pressure (SNIP). The aim of this interim analysis was to assess the potential for SNIP to be a surrogate for aerosol generating procedures given COVID-19 related restrictions. Methods: This was a prospective observational study. Patients attending six study sites with King's Stage 2 or 3 ALS completed baseline FVC/SVC/SNIP/PCF and repeated assessments 3 monthly. Data were collected from March 2018 to March 2020, after which a COVID-19 related study suspension was imposed. Correlations between the measures were calculated. A Bayesian multiple outcomes random-effects model was constructed to investigate rates of decline across measures. Results: In total, 270 cases and 828 assessments were included (Mean age 65.2 ± 15.4 years; 32.6% Female; 60% Kings stage 2; 81.1% spinal onset). FVC and SVC were the most closely correlated outcomes (0.95). SNIP showed the least correlation with other metrics 0.53 (FVC), 0.54 (SVC), 0.60 (PCF). All four measures significantly declined over time. SNIP in the bulbar onset group showed the fastest rate of decline. Discussion: SNIP was not well correlated with FVC and SVC, probably because it examines a different aspect of respiratory function. Respiratory measures declined over time, but differentially according to the site of onset. SNIP is not a surrogate for FVC and SVC, but is a complementary measure, declining linearly and differentiating spinal and bulbar onset patients.
Collapse
Affiliation(s)
- Deirdre Murray
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
| | - James Rooney
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Amar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Tommy Bunte
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theresa Chiwera
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Mutahhara Choudhury
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Adriano Chio
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology 1, Azienda Ospedale Università Città della Salute e della Scienza, Turin, Italy
| | - Lauren Fenton
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Jennifer Fortune
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Lindsay Maidment
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Umberto Manera
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Chris Mcdermott
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK.,Sheffield Institute for Translational Neuroscience, Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Dara Meldrum
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Myrte Meyjes
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rachel Tattersall
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
| | - Maria Claudia Torrieri
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Philip Van Damme
- Neurology Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and.,KU Leuven, Department of Neuroscience, Leuven Brain Institute and VIB Center for Brain & Disease Research, Leuven, Belgium
| | - Elien Vanderlinden
- Neurology Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and
| | - Claire Wood
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | | | - Orla Hardiman
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
| |
Collapse
|
42
|
Pronto-Laborinho AC, Lopes CS, Conceição VA, Gromicho M, Santos NC, de Carvalho M, Carvalho FA. γ' Fibrinogen as a Predictor of Survival in Amyotrophic Lateral Sclerosis. Front Cardiovasc Med 2021; 8:715842. [PMID: 34568457 PMCID: PMC8458885 DOI: 10.3389/fcvm.2021.715842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/09/2021] [Indexed: 12/05/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is an aggressive neurodegenerative disorder related to neuroinflammation that is associated with increased risk of thrombosis. We aimed to evaluate γ' fibrinogen plasma level (an in vivo variant of fibrinogen) as a biomarker in ALS, and to test its role as a predictor of disease progression and survival. Sixty-seven consecutive patients with ALS were followed and the results were compared with those from 82 healthy blood donors. Patients were clinically evaluated at the time of blood sampling and on follow-up (every 3 months for the beginning of the follow-up until death) by applying the revised ALS Functional Rating Scale. Human plasma γ' fibrinogen concentration was quantified using a specific two-site sandwich kit enzyme-linked immunosorbent assay. We found, for the first time, a positive association between γ' fibrinogen concentration and survival in ALS patients: patients with higher γ' fibrinogen plasma levels survived longer, and this finding was not influenced by confounders such as age, gender, respiratory impairment, or functionality (ALSFRS-R score). Since increased levels have a positive impact on outcome, this novel biomarker should be further investigated in ALS.
Collapse
Affiliation(s)
| | - Catarina S Lopes
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Vasco A Conceição
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Marta Gromicho
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nuno C Santos
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mamede de Carvalho
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - Filomena A Carvalho
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| |
Collapse
|
43
|
Chiò A, Canosa A, Calvo A, Moglia C, Cicolin A, Mora G. Developments in the assessment of non-motor disease progression in amyotrophic lateral sclerosis. Expert Rev Neurother 2021; 21:1419-1440. [PMID: 34554894 DOI: 10.1080/14737175.2021.1984883] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The burden of non-motor symptoms is a major determinant of quality of life and outcome in amyotrophic lateral sclerosis (ALS) and has profound negative effect also on caregivers. AREAS COVERED Non-motor symptoms in ALS include cognitive impairment, neurobehavioral symptoms, depression and anxiety, suicidal ideation, pain, disordered sleep, fatigue, weight loss and reduced appetite, and autonomic dysfunctions. This review summarizes the measures used for the assessment of non-motor symptoms and their properties and recaps the frequency and progression of these symptoms along the course of ALS. EXPERT OPINION Non-motor symptoms in ALS represent a major component of the disease and span over several domains. These symptoms require a high level of medical attention and should be checked at each visit using ad hoc questionnaires and proactively treated. Several instruments assessing non-motor symptoms have been used in ALS. Specific screening questionnaires for non-motor symptoms can be used for monitoring patients during telehealth visits and for remote surveillance through sensors and apps installed on smartphones. Novel trials for non-motor symptoms treatment specifically designed for ALS are necessary to increase and refine the therapeutic armamentarium. Finally, scales assessing the most frequent and burdensome non-motor symptoms should be included in clinical trials.
Collapse
Affiliation(s)
- Adriano Chiò
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology I, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Antonio Canosa
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology I, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Andrea Calvo
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology I, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Cristina Moglia
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology I, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Alessandro Cicolin
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Sleep Medicine Center, Azienda Ospedaliera Città Della Salute E Della Scienza of Turin, Turin, Italy
| | - Gabriele Mora
- Neurorehabilitation Department, Ics Maugeri Irccs, Institute of Milan, Milan, Italy
| |
Collapse
|
44
|
Carvalho MD, Swash M. Levosimendan for amyotrophic lateral sclerosis. Lancet Neurol 2021; 20:775-777. [PMID: 34536395 DOI: 10.1016/s1474-4422(21)00255-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Mamede de Carvalho
- Instituto de Fisiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Univeridade de Lisboa, Lisbon 1648-028, Portugal; Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal.
| | - Michael Swash
- Instituto de Fisiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Univeridade de Lisboa, Lisbon 1648-028, Portugal; Departments of Neurology and Neuroscience, Barts and The London School of Medicine, Queen Mary University of London, London, UK
| |
Collapse
|
45
|
Berry J, Brooks B, Genge A, Heiman-Patterson T, Appel S, Benatar M, Bowser R, Cudkowicz M, Gooch C, Shefner J, Westra J, Agnese W, Merrill C, Nelson S, Apple S. Radicava/Edaravone Findings in Biomarkers From Amyotrophic Lateral Sclerosis (REFINE-ALS): Protocol and Study Design. Neurol Clin Pract 2021; 11:e472-e479. [PMID: 34476128 PMCID: PMC8382414 DOI: 10.1212/cpj.0000000000000968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 09/03/2020] [Indexed: 11/15/2022]
Abstract
Objectives To identify putative biomarkers that may serve as quantifiable, biological, nonclinical measures of the pharmacodynamic effect of edaravone in amyotrophic lateral sclerosis (ALS) and to report real-world treatment outcomes. Methods This is a prospective, observational, longitudinal, multicenter (up to 40 sites) US study (Clinicaltrials.gov; NCT04259255) with at least 200 patients with ALS who will receive edaravone for 24 weeks (6 cycles; Food and Drug Administration-approved regimen). All participants must either be treatment naive for edaravone or be more than 1 month without receiving any edaravone dose before screening. Biomarker quantification and other assessments will be performed at baseline (before cycle 1) and during cycles 1, 3, and 6. Selected biomarkers of oxidative stress, inflammation, neuronal injury and death, and muscle injury, as well as biomarker discovery panels (EpiSwitch and SOMAscan), will be evaluated and, when feasible, compared with biobanked samples. Clinical efficacy assessments will include the ALS Functional Rating Scale-Revised, King's clinical staging, ALS Assessment Questionnaire-40, Appel ALS Score (Rating Scale), slow vital capacity, hand-held dynamometry and grip strength, and time to specified states of disease progression or death. DNA samples will also be collected for potential genomic evaluation. The predicted rates of progression and survival, and their potential correlations with biomarkers, will be evaluated. Adverse events related to the study will be reported. Results The study is estimated to be completed in 2022 with an interim analysis planned. Conclusions Findings may help to further the understanding of the pharmacodynamic effect of edaravone, including changes in biomarkers, in response to treatment.
Collapse
Affiliation(s)
- James Berry
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Benjamin Brooks
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Angela Genge
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Terry Heiman-Patterson
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Stanley Appel
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Michael Benatar
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Robert Bowser
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Merit Cudkowicz
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Clifton Gooch
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Jeremy Shefner
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Jurjen Westra
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Wendy Agnese
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Charlotte Merrill
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Sally Nelson
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| | - Stephen Apple
- Massachusetts General Hospital (JB), Boston; Atrium Health Neurosciences Institute (BB), Carolinas Medical Center, University of North Carolina School of Medicine-Charlotte Campus; Montreal Neurological Institute and Hospital (AG), QC, Canada; Lewis Katz School of Medicine (TH-P), Temple University, Philadelphia, PA; Houston Methodist (S. Appel), TX; University of Miami (MB), FL; Barrow Neurological Institute (RB, JS), Phoenix, AZ; Harvard Medical School (MC), Boston, MA; University of South Florida (CG), Tampa; Oxford BioDynamics Inc. (JW), Wilmington, DE; and Mitsubishi Tanabe Pharma America (WA, CM, SN, S. Apple), Inc., Jersey City, NJ
| |
Collapse
|
46
|
Gilmore M, Elman L, Babu S, Andres P, Floeter MK. Measuring disease progression in primary lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2021; 21:59-66. [PMID: 33602016 DOI: 10.1080/21678421.2020.1837179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Quantitative measures of disease severity are essential outcome measures for clinical trials. The slow progression of disease in primary lateral sclerosis (PLS) requires clinical measures that are sensitive to changes occurring within the time frame of a clinical trial. Proposed clinical outcome measures include the PLS functional rating scale (PLSFRS), burden scores derived from clinical examination findings, and quantitative measures of motor performance. The PLSFRS has good inter-rater reliability and showed greater longitudinal change over 6- and 12-months compared to the revised ALS functional rating scale. Examination-based upper motor neuron burden (UMNB) scales also have good reliability, and longitudinal studies are in process. Quantitative measures of strength, dexterity, gait, and speech have the potential to provide objective and precise measures of clinical change, but have been the least studied in persons with PLS.
Collapse
Affiliation(s)
- Madison Gilmore
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Lauren Elman
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Suma Babu
- Sean M Healy & AMG Center for ALS, Massachusetts General Hospital, Boston, MA, USA
| | - Patricia Andres
- Neurological Clinical Research Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Mary Kay Floeter
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| |
Collapse
|
47
|
Mora JS, Bradley WG, Chaverri D, Hernández-Barral M, Mascias J, Gamez J, Gargiulo-Monachelli GM, Moussy A, Mansfield CD, Hermine O, Ludolph AC. Long-term survival analysis of masitinib in amyotrophic lateral sclerosis. Ther Adv Neurol Disord 2021; 14:17562864211030365. [PMID: 34457038 PMCID: PMC8388186 DOI: 10.1177/17562864211030365] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background: A randomized, placebo-controlled phase III study (AB10015) previously demonstrated that orally administered masitinib (4.5 mg/kg/day) slowed rate of functional decline, with acceptable safety, in amyotrophic lateral sclerosis (ALS) patients having an ALS Functional Rating Scale-revised (ALSFRS-R) progression rate from disease onset to baseline of <1.1 points/month. Here we assess long-term overall survival (OS) data of all participants from study AB10015 and test whether a signal in OS is evident in an enriched patient population similar to that prospectively defined for confirmatory study AB19001. Methods: Survival status of all patients originally randomized in AB10015 was collected from participating investigational sites. Survival analysis (using the multivariate log-rank test and Cox proportional hazards model, with stratification factors as covariates) was performed on the intention-to-treat population and enriched subgroups, which were defined according to initial randomization, baseline ALSFRS-R progression rate and baseline disease severity. Results: A significant survival benefit of 25 months (p = 0.037) and 47% reduced risk of death (p = 0.025) was observed for patients receiving 4.5 mg/kg/day masitinib (n = 45) versus placebo (n = 62) in an enriched cohort with ⩾2 on each baseline ALSFRS-R individual component score (i.e. prior to any complete loss or severe impairment of functionality) and post-onset ALSFRS-R progression rate <1.1 (i.e. exclusion of very fast progressors) [median OS of 69 versus 44 months, respectively; hazard ratio, 0.53 [95% CI (0.31–0.92)]]. This corresponds to the population enrolled in confirmatory phase III study, AB19001. Conclusions: Analysis of long-term OS (75 months average follow-up from diagnosis) indicates that oral masitinib (4.5 mg/kg/day) could prolong survival by over 2 years as compared with placebo, provided that treatment starts prior to severe impairment of functionality. This trial was registered at www.ClinicalTrials.gov under identifier NCT02588677 (28 October 2015).
Collapse
Affiliation(s)
| | - Walter G Bradley
- Department of Neurology, University of Miami School of Medicine, Miami, FL, USA
| | - Delia Chaverri
- ALS Unit, Department of Neurology, University Hospital La Paz-Carlos III, Madrid, Spain
| | | | - Javier Mascias
- ALS Unit, Department of Neurology, University Hospital La Paz-Carlos III, Madrid, Spain
| | - Josep Gamez
- Neurology Department, GMA Clinic, Autonomous University of Barcelona, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Barcelona, Spain
| | | | | | | | - Olivier Hermine
- Department of Hematology, Necker Hospital, University of Paris, 149 Rue de Sèvres, Paris 75015, France
| | - Albert C Ludolph
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| |
Collapse
|
48
|
Witzel S, Frauhammer F, Steinacker P, Devos D, Pradat PF, Meininger V, Halbgebauer S, Oeckl P, Schuster J, Anders S, Dorst J, Otto M, Ludolph AC. Neurofilament light and heterogeneity of disease progression in amyotrophic lateral sclerosis: development and validation of a prediction model to improve interventional trials. Transl Neurodegener 2021; 10:31. [PMID: 34433481 PMCID: PMC8390195 DOI: 10.1186/s40035-021-00257-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Interventional trials in amyotrophic lateral sclerosis (ALS) suffer from the heterogeneity of the disease as it considerably reduces statistical power. We asked if blood neurofilament light chains (NfL) could be used to anticipate disease progression and increase trial power. Methods In 125 patients with ALS from three independent prospective studies—one observational study and two interventional trials—we developed and externally validated a multivariate linear model for predicting disease progression, measured by the monthly decrease of the ALS Functional Rating Scale Revised (ALSFRS-R) score. We trained the prediction model in the observational study and tested the predictive value of the following parameters assessed at diagnosis: NfL levels, sex, age, site of onset, body mass index, disease duration, ALSFRS-R score, and monthly ALSFRS-R score decrease since disease onset. We then applied the resulting model in the other two study cohorts to assess the actual utility for interventional trials. We analyzed the impact on trial power in mixed-effects models and compared the performance of the NfL model with two currently used predictive approaches, which anticipate disease progression using the ALSFRS-R decrease during a three-month observational period (lead-in) or since disease onset (ΔFRS). Results Among the parameters provided, the NfL levels (P < 0.001) and the interaction with site of onset (P < 0.01) contributed significantly to the prediction, forming a robust NfL prediction model (R = 0.67). Model application in the trial cohorts confirmed its applicability and revealed superiority over lead-in and ΔFRS-based approaches. The NfL model improved statistical power by 61% and 22% (95% confidence intervals: 54%–66%, 7%–29%). Conclusion The use of the NfL-based prediction model to compensate for clinical heterogeneity in ALS could significantly increase the trial power. NCT00868166, registered March
23, 2009; NCT02306590, registered December 2, 2014. Supplementary Information The online version contains supplementary material available at 10.1186/s40035-021-00257-y.
Collapse
Affiliation(s)
- Simon Witzel
- Department of Neurology, University of Ulm, Ulm, Germany.
| | - Felix Frauhammer
- Center for Molecular Biology, Heidelberg University, Heidelberg, Germany
| | | | - David Devos
- Department of Medical Pharmacology, Expert center for Parkinson, CHU-Lille, Lille Neuroscience and Cognition, Inserm, UMR-S1172, LICEND, NS-Park Network, University of Lille, Lille, France
| | | | - Vincent Meininger
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Patrick Oeckl
- Department of Neurology, University of Ulm, Ulm, Germany
| | | | - Simon Anders
- Center for Molecular Biology, Heidelberg University, Heidelberg, Germany
| | - Johannes Dorst
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Markus Otto
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Albert C Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany.,German Centre for Neurodegenerative Diseases (DZNE) Site Ulm, Ulm, Germany
| |
Collapse
|
49
|
Torrieri MC, Manera U, Mora G, Canosa A, Vasta R, Fuda G, Salamone P, Grassano M, Cugnasco P, Launaro N, De Marchi F, Mattei A, Mazzini L, Moglia C, Calvo A, Chiò A. Tailoring patients' enrollment in ALS clinical trials: the effect of disease duration and vital capacity cutoffs. Amyotroph Lateral Scler Frontotemporal Degener 2021; 23:108-115. [PMID: 34355622 DOI: 10.1080/21678421.2021.1936063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: To evaluate how Amyotrophic Lateral Sclerosis (ALS) patients' mortality rates change, based on different levels of forced vital capacity (FVC) and disease duration, providing a scheme of mortality rates of a real population of ALS patients to improve the design of future RCTs. Methods: One random spirometry for each ALS patient was selected during four time intervals from disease onset: (1) ≤12 months; (2) ≤18 months; (3) ≤24 months; (4) ≤36 months. Date of spirometry corresponded to date of trial entry, while time interval onset-spirometry to disease duration at enrollment. Mortality rates from inclusion were computed at different time intervals. Based on progression rates, patients were stratified in slow, intermediate and fast progressors. Survival from recruitment was calculated depending on FVC, disease duration and progression rate. Results: We included 659 patients in group 1, 888 in group 2, 1019 in group 3 and 1102 in group 4. Mortality rates were higher in each group at reducing the FVC cutoff used for recruitment (p < 0.001). Median survival decreased when lowering FVC and disease duration cutoffs (p < 0.001); a higher median disease progression rate of included patients led to lower median survival from recruitment. The proportion of recruited fast progressors raised when shortening disease duration and lowering FVC cutoff. Conclusions: This is a simple model for setting eligibility criteria, based on mortality rates of patients depending on FVC and disease duration, to select the best population for RCTs, tailored to trials' primary endpoints and duration.
Collapse
Affiliation(s)
| | - Umberto Manera
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Gabriele Mora
- Neurorehabilitation Department, Institute of Milan, ICS Maugeri IRCCS, Milan, Italy
| | - Antonio Canosa
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology 1, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Rosario Vasta
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Giuseppe Fuda
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Paolina Salamone
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Maurizio Grassano
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Paolo Cugnasco
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Nicola Launaro
- Respiratory Intensive Care Unit, Presidio Ospedaliero di Saluzzo, Saluzzo, Italy
| | - Fabiola De Marchi
- Department of Neurology and ALS Centre, Maggiore della Carità Hospital, University of Piemonte Orientale, Novara, Italy, and
| | - Alessio Mattei
- Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, S.C. Pneumologia U, Turin, Italy
| | - Letizia Mazzini
- Department of Neurology and ALS Centre, Maggiore della Carità Hospital, University of Piemonte Orientale, Novara, Italy, and
| | - Cristina Moglia
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology 1, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Andrea Calvo
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology 1, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Adriano Chiò
- Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology 1, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| |
Collapse
|
50
|
van Eijk RPA, Nikolakopoulos S, Roes KCB, Kendall L, Han SS, Lavrov A, Epstein N, Kliest T, de Jongh AD, Westeneng HJ, Al-Chalabi A, Van Damme P, Hardiman O, Shaw PJ, McDermott CJ, Eijkemans MJC, van den Berg LH. Challenging the Established Order: Innovating Clinical Trials for Amyotrophic Lateral Sclerosis. Neurology 2021; 97:528-536. [PMID: 34315786 PMCID: PMC8456357 DOI: 10.1212/wnl.0000000000012545] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/09/2021] [Indexed: 11/15/2022] Open
Abstract
Development of effective treatments for amyotrophic lateral sclerosis (ALS) has been hampered by disease heterogeneity, a limited understanding of underlying pathophysiology, and methodologic design challenges. We have evaluated 2 major themes in the design of pivotal, phase 3 clinical trials for ALS—(1) patient selection and (2) analytical strategy—and discussed potential solutions with the European Medicines Agency. Several design considerations were assessed using data from 5 placebo-controlled clinical trials (n = 988), 4 population-based cohorts (n = 5,100), and 2,436 placebo-allocated patients from the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) database. The validity of each proposed design modification was confirmed by means of simulation and illustrated for a hypothetical setting. Compared to classical trial design, the proposed design modifications reduce the sample size by 30.5% and placebo exposure time by 35.4%. By making use of prognostic survival models, one creates a potential to include a larger proportion of the population and maximize generalizability. We propose a flexible design framework that naturally adapts the trial duration when inaccurate assumptions are made at the design stage, such as enrollment or survival rate. In case of futility, the follow-up time is shortened and patient exposure to ineffective treatments or placebo is minimized. For diseases such as ALS, optimizing the use of resources, widening eligibility criteria, and minimizing exposure to futile treatments and placebo is critical to the development of effective treatments. Our proposed design modifications could circumvent important pitfalls and may serve as a blueprint for future clinical trials in this population.
Collapse
Affiliation(s)
- Ruben P A van Eijk
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands. .,Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stavros Nikolakopoulos
- Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Section Biostatistics, Radboud Medical Centre Nijmegen, the Netherlands
| | | | - Steve S Han
- Neurosciences, Takeda Pharmaceuticals, Cambridge, USA.,Discovery Medicine, GlaxoSmithKline R&D, Upper Providence, USA
| | - Arseniy Lavrov
- Clinical Development, Novartis Gene Therapies, London, UK.,Clinical Translational Medicine, Future Pipeline Discovery, GlaxoSmithKline R&D, Middlesex, UK
| | - Noam Epstein
- Discovery Medicine, GlaxoSmithKline R&D, Upper Providence, USA
| | - Tessa Kliest
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Adriaan D de Jongh
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Henk-Jan Westeneng
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ammar Al-Chalabi
- King's College London, London, Maurice Wohl Clinical Neuroscience Institute and United Kingdom Dementia Research Institute Centre, Department of Basic and Clinical Neuroscience, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Philip Van Damme
- Department of Neurosciences, Laboratory for Neurobiology, KU Leuven and Center for Brain & Disease Research, VIB, Leuven Brain Institute, Leuven, Belgium.,Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Orla Hardiman
- Department of Neurology, National Neuroscience Centre, Beaumont Hospital, Dublin, Ireland.,FutureNeuro SFI Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pamela J Shaw
- Department of Neuroscience, University of Sheffield, Sheffield Institute for Translational Neuroscience, Sheffield, UK
| | - Christopher J McDermott
- Department of Neuroscience, University of Sheffield, Sheffield Institute for Translational Neuroscience, Sheffield, UK
| | - Marinus J C Eijkemans
- Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|