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Meyer T, Dreger M, Grehl T, Weyen U, Kettemann D, Weydt P, Günther R, Lingor P, Petri S, Koch JC, Großkreutz J, Rödiger A, Baum P, Hermann A, Prudlo J, Boentert M, Weishaupt JH, Löscher WN, Dorst J, Koc Y, Bernsen S, Cordts I, Vidovic M, Steinbach R, Metelmann M, Kleinveld VE, Norden J, Ludolph A, Walter B, Schumann P, Münch C, Körtvélyessy P, Maier A. Serum neurofilament light chain in distinct phenotypes of amyotrophic lateral sclerosis: A longitudinal, multicenter study. Eur J Neurol 2024; 31:e16379. [PMID: 38859579 PMCID: PMC11295170 DOI: 10.1111/ene.16379] [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: 02/25/2024] [Revised: 05/01/2024] [Accepted: 05/21/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To assess the performance of serum neurofilament light chain (sNfL) in clinical phenotypes of amyotrophic lateral sclerosis (ALS). METHODS In 2949 ALS patients at 16 ALS centers in Germany and Austria, clinical characteristics and sNfL were assessed. Phenotypes were differentiated for two anatomical determinants: (1) upper and/or lower motor involvement (typical, typMN; upper/lower motor neuron predominant, UMNp/LMNp; primary lateral sclerosis, PLS) and (2) region of onset and propagation of motor neuron dysfunction (bulbar, limb, flail-arm, flail-leg, thoracic onset). Phenotypes were correlated to sNfL, progression, and survival. RESULTS Mean sNfL was - compared to typMN (75.7 pg/mL, n = 1791) - significantly lower in LMNp (45.1 pg/mL, n = 413), UMNp (58.7 pg/mL n = 206), and PLS (37.6 pg/mL, n = 84). Also, sNfL significantly differed in the bulbar (92.7 pg/mL, n = 669), limb (64.1 pg/mL, n = 1305), flail-arm (46.4 pg/mL, n = 283), flail-leg (53.6 pg/mL, n = 141), and thoracic (74.5 pg/mL, n = 96) phenotypes. Binary logistic regression analysis showed highest contribution to sNfL elevation for faster progression (odds ratio [OR] 3.24) and for the bulbar onset phenotype (OR 1.94). In contrast, PLS (OR 0.20), LMNp (OR 0.45), and thoracic onset (OR 0.43) showed reduced contributions to sNfL. Longitudinal sNfL (median 12 months, n = 2862) showed minor monthly changes (<0.2%) across all phenotypes. Correlation of sNfL with survival was confirmed (p < 0.001). CONCLUSIONS This study underscored the correlation of ALS phenotypes - differentiated for motor neuron involvement and region of onset/propagation - with sNfL, progression, and survival. These phenotypes demonstrated a significant effect on sNfL and should be recognized as independent confounders of sNfL analyses in ALS trials and clinical practice.
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Affiliation(s)
- Thomas Meyer
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
- Ambulanzpartner Soziotechnologie APST GmbHBerlinGermany
| | - Marie Dreger
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Torsten Grehl
- Department of NeurologyCenter for ALS and Other Motor Neuron Disorders, Alfried Krupp KrankenhausEssenGermany
| | - Ute Weyen
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersBerufsgenossenschaftliches Universitätsklinikum BergmannsheilBochumGermany
| | - Dagmar Kettemann
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Patrick Weydt
- Department for Neuromuscular DisordersBonn UniversityBonnGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)BonnGermany
| | - René Günther
- Department of NeurologyTechnische Universität Dresden, University Hospital Carl Gustav CarusDresdenGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)DresdenGermany
| | - Paul Lingor
- Department of NeurologyTechnical University of Munich, School of Medicine, Klinikum rechts der IsarMunichGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)MunichGermany
| | - Susanne Petri
- Department of NeurologyHannover Medical SchoolHannoverGermany
| | | | - Julian Großkreutz
- Department of NeurologyUniversitätsmedizin Schleswig‐Holstein, Campus LübeckLübeckGermany
| | - Annekathrin Rödiger
- Department of NeurologyJena University HospitalJenaGermany
- Zentrum für Seltene Erkrankungen (ZSE)Jena University HospitalJenaGermany
| | - Petra Baum
- Department of NeurologyUniversity Hospital LeipzigLeipzigGermany
| | - Andreas Hermann
- Translational Neurodegeneration Section “Albrecht‐Kossel”, Department of NeurologyUniversity of Rostock, University Medical CenterRostockGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)GreifswaldGermany
| | - Johannes Prudlo
- Translational Neurodegeneration Section “Albrecht‐Kossel”, Department of NeurologyUniversity of Rostock, University Medical CenterRostockGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)GreifswaldGermany
| | | | - Jochen H. Weishaupt
- Division for Neurodegenerative Diseases, Neurology Department, Mannheim Center for Translational MedicineUniversity Medicine Mannheim, Heidelberg UniversityMannheimGermany
| | | | - Johannes Dorst
- Department of NeurologyUlm UniversityUlmGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)UlmGermany
| | - Yasemin Koc
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Sarah Bernsen
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
- Department for Neuromuscular DisordersBonn UniversityBonnGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)BonnGermany
| | - Isabell Cordts
- Department of NeurologyTechnical University of Munich, School of Medicine, Klinikum rechts der IsarMunichGermany
| | - Maximilian Vidovic
- Department of NeurologyTechnische Universität Dresden, University Hospital Carl Gustav CarusDresdenGermany
| | | | - Moritz Metelmann
- Department of NeurologyUniversity Hospital LeipzigLeipzigGermany
| | | | - Jenny Norden
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Albert Ludolph
- Department of NeurologyUlm UniversityUlmGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)UlmGermany
| | - Bertram Walter
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Peggy Schumann
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
- Ambulanzpartner Soziotechnologie APST GmbHBerlinGermany
| | - Christoph Münch
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
- Ambulanzpartner Soziotechnologie APST GmbHBerlinGermany
| | - Péter Körtvélyessy
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - André Maier
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
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Han M, Raymond J, Larson TC, Mehta P, Horton DK. Comparison of Demographics: National Amyotrophic Lateral Sclerosis Registry and Clinical Trials Data. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02047-4. [PMID: 38977656 DOI: 10.1007/s40615-024-02047-4] [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: 01/31/2024] [Revised: 01/31/2024] [Accepted: 05/31/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVE To characterize the participant demographics in the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) database compared with the web-portal National Amyotrophic Lateral Sclerosis (ALS) Registry (the Registry). METHODS Demographics and ALS symptom information were compared between the self-reported registrant data in the Registry web portal (2010-2021) and the latest available PRO-ACT data (updated August 2022), which is a collection of clinical trials data. RESULTS Greater percentages of younger (≤ 59 years old) but smaller percentages of older (60 + years old) participants were represented in PRO-ACT compared to Registry. Enrollment for minority race groups was greater in the Registry portal data, but race information was largely missing/unknown in PRO-ACT database. Median age at the time of diagnosis and age at the time of symptom onset were significantly higher for Registry enrollees compared to the participants of PRO-ACT. Symptom onset sites were similarly reported, but duration between self-noted symptom onset and diagnosis was slight, but significantly longer for the Registry enrollees (11 vs. 9 months). Hispanic were as likely as non-Hispanic to participate in research studies, based on the Registry data. CONCLUSION There was a notable difference in the age distribution and minority representation of enrollees between the PRO-ACT and Registry study populations. Age distribution in the PRO-ACT database skewed to a younger and less diverse cohort. Despite the clinical heterogeneity and complex disease mechanism of ALS, identifying the underrepresented demographic niche in the PRO-ACT and Registry study populations can help improve patient participation and criteria for patient selection to enhance generalizability.
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Affiliation(s)
- Moon Han
- Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, 30341, USA.
| | - Jaime Raymond
- Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, 30341, USA
| | - Theodore C Larson
- Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, 30341, USA
| | - Paul Mehta
- Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, 30341, USA
| | - D Kevin Horton
- Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, 30341, USA
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3
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Hardiman O. Amyotrophic lateral sclerosis: a lesson in translation. Lancet Neurol 2024; 23:651-653. [PMID: 38782014 DOI: 10.1016/s1474-4422(24)00223-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Orla Hardiman
- Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland.
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Tsai CC, Tao B, Wong M, Suntharalingam H, Abrahao A, Barnett-Tapia C. Sex, racial, and ethnic disparities in motor neuron disease: clinical trial enrolment. Amyotroph Lateral Scler Frontotemporal Degener 2024:1-8. [PMID: 38835201 DOI: 10.1080/21678421.2024.2358793] [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: 04/04/2024] [Accepted: 05/12/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVE Motor neuron disease (MND) is a group of neurological diseases, the majority being amyotrophic lateral sclerosis (ALS), with varying clinical presentations across demographics. Clinical trial enrollment reflecting global disease burden improves understanding of diverse presentations and aids personalized therapy development. We assessed the sex, racial, and ethnic composition of MND/ALS clinical trial participants relative to global disease burdens. METHODS We searched 'motor neuron disease OR amyotrophic lateral sclerosis' on ClinicalTrials.gov from 02/2000-04/2024. We extracted trial (start year, study site, sponsor location, phase, masking, intervention) and demographic data (sex, race, ethnicity) from randomized interventional studies. We obtained sex-based MND/ALS disease burden estimates from the Global Burden of Disease database. For females, we calculated pooled participation-to-prevalence ratio (PPR) with 95% confidence intervals (CIs), with PPR of 0.8-1.2 indicating adequate enrollment. We used Kruskal-Wallis tests to compare demographic groups across trial characteristics. RESULTS Of 85 trials, females comprised 37.47% (n = 5011) of 13,372 participants; the pooled female PPR was 0.97 (95% CI: 0.77-1.16). Of 41 trials (9340 participants) reporting race, 121 (1.30%) participants were Black or African American, 16 (0.17%) American Indian or Alaskan Native, and 6 (0.06%) Native Hawaiian or Other Pacific Islander. 24 trials (595 participants) reported ethnicity, with a minority of Hispanic participants (n = 153; 2.57%). CONCLUSIONS MND/ALS clinical trials had adequate female enrollment relative to global disease burdens. Race and ethnicity data were underreported. However, there were enrollment disparities of racial and ethnic groups. Increased trial leadership diversity, equitable enrollment policies, and addressing barriers to participation could improve enrollment diversity.
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Affiliation(s)
- Chia-Chen Tsai
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brendan Tao
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Madeleine Wong
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | | | - Agessandro Abrahao
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Carolina Barnett-Tapia
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, Toronto, ON, Canada, and
- Division of Neurology, University of Toronto, Toronto, ON, Canada
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Evans LJ, O'Brien D, Shaw PJ. Current neuroprotective therapies and future prospects for motor neuron disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:327-384. [PMID: 38802178 DOI: 10.1016/bs.irn.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Four medications with neuroprotective disease-modifying effects are now in use for motor neuron disease (MND). With FDA approvals for tofersen, relyvrio and edaravone in just the past year, 2022 ended a quarter of a century when riluzole was the sole such drug to offer to patients. The acceleration of approvals may mean we are witnessing the beginning of a step-change in how MND can be treated. Improvements in understanding underlying disease biology has led to more therapies being developed to target specific and multiple disease mechanisms. Consideration for how the pipeline of new therapeutic agents coming through in clinical and preclinical development can be more effectively evaluated with biomarkers, advances in patient stratification and clinical trial design pave the way for more successful translation for this archetypal complex neurodegenerative disease. While it must be cautioned that only slowed rates of progression have so far been demonstrated, pre-empting rapid neurodegeneration by using neurofilament biomarkers to signal when to treat, as is currently being trialled with tofersen, may be more effective for patients with known genetic predisposition to MND. Early intervention with personalized medicines could mean that for some patients at least, in future we may be able to substantially treat what is considered by many to be one of the most distressing diseases in medicine.
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Affiliation(s)
- Laura J Evans
- The Sheffield Institute for Translational Neuroscience, and the NIHR Sheffield Biomedical Research Centre, University of Sheffield, Sheffield, United Kingdom
| | - David O'Brien
- The Sheffield Institute for Translational Neuroscience, and the NIHR Sheffield Biomedical Research Centre, University of Sheffield, Sheffield, United Kingdom
| | - Pamela J Shaw
- The Sheffield Institute for Translational Neuroscience, and the NIHR Sheffield Biomedical Research Centre, University of Sheffield, Sheffield, United Kingdom.
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Young CA, Chaouch A, Mcdermott CJ, Al-Chalabi A, Chhetri SK, Talbot K, Malaspina A, Mills R, Tennant A. Improving the measurement properties of the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R): deriving a valid measurement total for the calculation of change. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:400-409. [PMID: 38426231 PMCID: PMC11262430 DOI: 10.1080/21678421.2024.2322539] [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: 08/29/2023] [Accepted: 02/19/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) total score is a widely used measure of functional status in Amyotrophic Lateral Sclerosis/Motor Neuron Disease (ALS), but recent evidence has raised doubts about its validity. The objective was to examine the measurement properties of the ALSFRS-R, aiming to produce valid measurement from all 12 scale items. METHOD Longitudinal ALSFRS-R data were collected between 2013-2020 from 1120 people with ALS recruited from 35 centers, together with other scales in the Trajectories of Outcomes in Neurological Conditions-ALS (TONiC-ALS) study. The ALSFRS-R was analyzed by confirmatory factor analysis (CFA), Rasch Analysis (RA) and Mokken scaling. RESULTS No definite factor structure of the ALSFRS-R was confirmed by CFA. RA revealed the raw score total to be invalid even at the ordinal level because of multidimensionality; valid interval level subscale measures could be found for the Bulbar, Fine-Motor and Gross-Motor domains but the Respiratory domain was only valid at an ordinal level. All four domains resolved into a single valid, interval level measure by using a bifactor RA. The smallest detectable difference was 10.4% of the range of the interval scale. CONCLUSION A total ALSFRS-R ordinal raw score can lead to inferential bias in clinical trial results due to its non-linear nature. On the interval level transformation, more than 5 points difference is required before a statistically significant detectable difference can be observed. Transformation to interval level data should be mandatory in clinical trials.
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Affiliation(s)
- Carolyn A Young
- Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Pharmacology and Therapeutics, University of Liverpool, UK
| | - Amina Chaouch
- Greater Manchester Centre for Clinical Neurosciences, Salford, UK
| | | | - Ammar Al-Chalabi
- Maurice Wohl Clinical Neuroscience Institute, Department of Basic and Clinical Neuroscience, King’s College London, London, UK
- Department of Neurology, King’s College Hospital, London, UK
| | | | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Roger Mills
- Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Pharmacology and Therapeutics, University of Liverpool, UK
| | - Alan Tennant
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, UK
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García-Parra B, Guiu JM, Povedano M, Mariño EL, Modamio P. Geographical distribution of clinical trials in amyotrophic lateral sclerosis: a scoping review. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:376-381. [PMID: 38393299 DOI: 10.1080/21678421.2024.2320881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/12/2024] [Indexed: 02/25/2024]
Abstract
Introduction: Clinical trials location is determined by many factors, including the availability of patient populations, regulatory environment, scientific expertise, and cost considerations. In clinical drug development of amyotrophic lateral sclerosis (ALS), where genetic differences have been described and may be related to geographic setting, this could have implications for the clinical interpretation of results in underrepresented geographic settings. Objective: The aim of this study was to review country participation in ALS clinical research based on available data from clinical trial registries and databases. Methods: We performed a scoping review with available information about clinical trials on ALS in ClinicalTrials.gov (CT), EU clinical trials register (EudraCT), WHO International Clinical Trials Registry Platform (ICTRP) and Web of Science (WOS). Inclusion criteria were clinical trials in phase 2 and 3 to treat ALS, recruiting or active not recruiting, from 23/06/2018 to 23/06/2023. Results: The total number of clinical trials identified were 188; 54 studies in CT, 38 in EudraCT, 47 in ICTRP and 49 in WOS. We identified 77 clinical trials after deleting duplicates and applying exclusion criteria. The countries with most studies conducted were the US with 35 studies (10.9%), followed by the United Kingdom, Belgium, France and Germany with 21 studies each one of them (6.5%). Conclusion: The data obtained in our review showed a non-homogeneous distribution in clinical trials at the international level, which may influence the interpretation of the results obtained.
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Affiliation(s)
- Beliu García-Parra
- Clinical Neurophysiology Section - Neurology Service, Bellvitge University Hospital. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M Guiu
- Clinical Pharmacy and Pharmaceutical Care Unit, Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Barcelona, Spain, and
| | - Mónica Povedano
- Clinical Neurophysiology Section - Neurology Service, Bellvitge University Hospital. L'Hospitalet de Llobregat, Barcelona, Spain
- Motor Neuron Diseases Unit, Bellvitge University Hospital. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eduardo L Mariño
- Clinical Pharmacy and Pharmaceutical Care Unit, Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Barcelona, Spain, and
| | - Pilar Modamio
- Clinical Pharmacy and Pharmaceutical Care Unit, Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Barcelona, Spain, and
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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).
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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.
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Devanarayan V, Ye Y, Charil A, Andreozzi E, Sachdev P, Llano DA, Tian L, Zhu L, Hampel H, Kramer L, Dhadda S, Irizarry M. Predicting clinical progression trajectories of early Alzheimer's disease patients. Alzheimers Dement 2024; 20:1725-1738. [PMID: 38087949 PMCID: PMC10984448 DOI: 10.1002/alz.13565] [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: 04/26/2023] [Revised: 09/06/2023] [Accepted: 11/07/2023] [Indexed: 03/16/2024]
Abstract
BACKGROUND Models for forecasting individual clinical progression trajectories in early Alzheimer's disease (AD) are needed for optimizing clinical studies and patient monitoring. METHODS Prediction models were constructed using a clinical trial training cohort (TC; n = 934) via a gradient boosting algorithm and then evaluated in two validation cohorts (VC 1, n = 235; VC 2, n = 421). Model inputs included baseline clinical features (cognitive function assessments, APOE ε4 status, and demographics) and brain magnetic resonance imaging (MRI) measures. RESULTS The model using clinical features achieved R2 of 0.21 and 0.31 for predicting 2-year cognitive decline in VC 1 and VC 2, respectively. Adding MRI features improved the R2 to 0.29 in VC 1, which employed the same preprocessing pipeline as the TC. Utilizing these model-based predictions for clinical trial enrichment reduced the required sample size by 20% to 49%. DISCUSSION Our validated prediction models enable baseline prediction of clinical progression trajectories in early AD, benefiting clinical trial enrichment and various applications.
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Affiliation(s)
- Viswanath Devanarayan
- Clinical Evidence GenerationEisai Inc.NutleyNew JerseyUSA
- Department of MathematicsStatistics and Computer ScienceUniversity of Illinois ChicagoChicagoIllinoisUSA
| | - Yuanqing Ye
- Clinical Evidence GenerationEisai Inc.NutleyNew JerseyUSA
| | - Arnaud Charil
- Clinical Evidence GenerationEisai Inc.NutleyNew JerseyUSA
| | | | | | - Daniel A. Llano
- Carle Illinois College of MedicineUrbanaIllinoisUSA
- Department of Molecular and Integrative PhysiologyUniversity of Illinois Urbana‐ChampaignUrbanaIllinoisUSA
| | - Lu Tian
- Department of Biomedical Data ScienceStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Liang Zhu
- Clinical Evidence GenerationEisai Inc.NutleyNew JerseyUSA
| | - Harald Hampel
- Clinical Evidence GenerationEisai Inc.NutleyNew JerseyUSA
| | - Lynn Kramer
- Clinical Evidence GenerationEisai Inc.NutleyNew JerseyUSA
| | - Shobha Dhadda
- Clinical Evidence GenerationEisai Inc.NutleyNew JerseyUSA
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Weemering DN, Midei M, Milner P, Gopalakrishnan V, Kumar A, Dannenberg AJ, Bunte TM, Foucher J, Ingre C, Ķēniņa V, Rallmann K, van den Berg LH, van Eijk RPA. A randomized, double-blind, placebo-controlled phase 2 study to assess safety, tolerability, and efficacy of RT001 in patients with amyotrophic lateral sclerosis. Eur J Neurol 2023; 30:3722-3731. [PMID: 37550954 DOI: 10.1111/ene.16020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/20/2023] [Accepted: 07/30/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND AND PURPOSE RT001 is a deuterated synthetic homologue of linoleic acid, which makes membrane polyunsaturated fatty acids resistant to lipid peroxidation, a process involved in motor neuron degeneration in amyotrophic lateral sclerosis (ALS). METHODS We conducted a randomized, multicenter, placebo-controlled clinical trial. Patients with ALS were randomly allocated to receive either RT001 or placebo for 24 weeks. After the double-blind period, all patients received RT001 during an open-label phase for 24 weeks. The primary outcome measures were safety and tolerability. Key efficacy outcomes included the ALS Functional Rating Scale (ALSFRS-R), percent predicted slow vital capacity, and plasma neurofilament light chain concentration. RESULTS In total, 43 patients (RT001 = 21; placebo = 22) were randomized. RT001 was well tolerated; one patient required dose reduction due to adverse events (AEs). Numerically, there were more AEs in the RT001 group compared to the placebo group (71% versus 55%, p = 0.35), with gastrointestinal symptoms being the most common (43% in RT001, 27% in placebo, p = 0.35). Two patients in the RT001 group experienced a serious AE, though unrelated to treatment. The least-squares mean difference in ALSFRS-R total score at week 24 of treatment was 1.90 (95% confidence interval = -1.39 to 5.19) in favor of RT001 (p = 0.25). The directions of other efficacy outcomes favored RT001 compared to placebo, although no inferential statistics were performed. CONCLUSIONS Initial data indicate that RT001 is safe and well tolerated. Given the exploratory nature of the study, a larger clinical trial is required to evaluate its efficacy.
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Affiliation(s)
- Daphne N Weemering
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark Midei
- BioJiva, LLC, Los Altos, California, USA
| | | | | | - Anil Kumar
- BioJiva, LLC, Los Altos, California, USA
| | | | - Tommy M Bunte
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Juliette Foucher
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, ME Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Ingre
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, ME Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Viktorija Ķēniņa
- Rare Neurological Disease Centre, Riga Stradinš Clinical University Hospital, Riga, Latvia
- Department of Biology and Microbiology, Riga Stradinš University, Riga, Latvia
| | - Karin Rallmann
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - 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
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11
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Gupta AS, Patel S, Premasiri A, Vieira F. At-home wearables and machine learning sensitively capture disease progression in amyotrophic lateral sclerosis. Nat Commun 2023; 14:5080. [PMID: 37604821 PMCID: PMC10442344 DOI: 10.1038/s41467-023-40917-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/04/2023] [Indexed: 08/23/2023] Open
Abstract
Amyotrophic lateral sclerosis causes degeneration of motor neurons, resulting in progressive muscle weakness and impairment in motor function. Promising drug development efforts have accelerated in amyotrophic lateral sclerosis, but are constrained by a lack of objective, sensitive, and accessible outcome measures. Here we investigate the use of wearable sensors, worn on four limbs at home during natural behavior, to quantify motor function and disease progression in 376 individuals with amyotrophic lateral sclerosis. We use an analysis approach that automatically detects and characterizes submovements from passively collected accelerometer data and produces a machine-learned severity score for each limb that is independent of clinical ratings. We show that this approach produces scores that progress faster than the gold standard Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (-0.86 ± 0.70 SD/year versus -0.73 ± 0.74 SD/year), resulting in smaller clinical trial sample size estimates (N = 76 versus N = 121). This method offers an ecologically valid and scalable measure for potential use in amyotrophic lateral sclerosis trials and clinical care.
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Affiliation(s)
- Anoopum S Gupta
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Siddharth Patel
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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12
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Vucic S, Menon P, Huynh W, Mahoney C, Ho KS, Hartford A, Rynders A, Evan J, Evan J, Ligozio S, Glanzman R, Hotchkin MT, Kiernan MC. Efficacy and safety of CNM-Au8 in amyotrophic lateral sclerosis (RESCUE-ALS study): a phase 2, randomised, double-blind, placebo-controlled trial and open label extension. EClinicalMedicine 2023; 60:102036. [PMID: 37396808 PMCID: PMC10314176 DOI: 10.1016/j.eclinm.2023.102036] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
Background CNM-Au8® is a catalytically-active gold nanocrystal neuroprotective agent that enhances intracellular energy metabolism and reduces oxidative stress. The phase 2, randomised, double-blind, placebo-controlled trial and open label extension RESCUE-ALS trial evaluated the efficacy and safety of CNM-Au8 for treatment of amyotrophic lateral sclerosis (ALS). Methods RESCUE-ALS and its long-term open label extension (OLE) were conducted at two multidisciplinary ALS clinics located in Sydney, Australia: (i) the Brain and Mind Centre and (ii) Westmead Hospital. The double-blind portion of RESCUE-ALS was conducted from January 16, 2020 (baseline visit, first-patient first-visit (FPFV)) through July 13, 2021 (double-blind period, last-patient last-visit (LPLV)). Participants (N = 45) were randomised 1:1 to receive 30 mg of CNM-Au8 or matching placebo daily over 36 weeks in addition to background standard of care, riluzole. The primary outcome was mean percent change in summed motor unit number index (MUNIX), a sensitive neurophysiological biomarker of lower motor neuron function. Change in total (or summated) MUNIX score and change in forced vital capacity (FVC) were secondary outcome measures. ALS disease progression events, ALS Functional Rating Scale (ALSFRS-R) change, change in quality of life (ALSSQOL-SF) were assessed as exploratory outcome measures. Long-term survival evaluated vital status of original active versus placebo randomisation for all participants through at least 12 months following last-patient last-visit (LPLV) of the double-blind period. RESCUE-ALS and the open label study are registered in clinicaltrials.gov with registration numbers NCT04098406 and NCT05299658, respectively. Findings In the intention-to-treat (ITT) population, there was no significant difference in the summated MUNIX score percent change (LS mean difference: 7.7%, 95% CI: -11.9 to 27.3%, p = 0.43), total MUNIX score change (18.8, 95% CI: -56.4 to 94.0), or FVC change (LS mean difference: 3.6, 95% CI: -12.4 to 19.7) between the active and placebo treated groups at week 36. In contrast, survival analyses through 12-month LPLV demonstrated a 60% reduction in all-cause mortality with CNM-Au8 treatment [hazard ratio = 0.408 (95% Wald CI: 0.166 to 1.001, log-rank p = 0.0429). 36 participants entered the open label extension (OLE), and those initially randomised to CNM-Au8 exhibited a slower rate of disease progression, as measured by time to the occurrence of death, tracheostomy, initiation of non-invasive ventilatory support, or gastrostomy tube placement. CNM-Au8 was well-tolerated, and no safety signals were observed. Interpretation CNM-Au8, in combination with riluzole, was well-tolerated in ALS with no identified safety signals. While the primary and secondary outcomes of this trial were not significant, the clinically meaningful exploratory results support further investigation of CNM-Au8 in ALS. Funding The RESCUE-ALS was substantially funded by a grant from FightMND. Additional funding was provided by Clene Australia Pty Ltd.
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Affiliation(s)
- Steve Vucic
- Brain and Nerve Research Centre, Concord Clinical School and Department of Neurology, Concord Repatriation General Hospital, The University of Sydney, Sydney, Australia
| | - Parvathi Menon
- Brain and Nerve Research Centre, Concord Clinical School and Department of Neurology, Concord Repatriation General Hospital, The University of Sydney, Sydney, Australia
| | - William Huynh
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Colin Mahoney
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Karen S. Ho
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | | | | | - Jacob Evan
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | - Jeremy Evan
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | | | | | | | - Matthew C. Kiernan
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
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13
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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: 109] [Impact Index Per Article: 109.0] [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.
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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.
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14
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Willemse SW, Roes KCB, Van Damme P, Hardiman O, Ingre C, Povedano M, Wray NR, Gijzen M, de Pagter MS, Demaegd KC, Janse AFC, Vink RG, Sleutjes BTHM, Chiò A, Corcia P, Reviers E, Al-Chalabi A, Kiernan MC, van den Berg LH, van Es MA, van Eijk RPA. Lithium carbonate in amyotrophic lateral sclerosis patients homozygous for the C-allele at SNP rs12608932 in UNC13A: protocol for a confirmatory, randomized, group-sequential, event-driven, double-blind, placebo-controlled trial. Trials 2022; 23:978. [PMID: 36471413 PMCID: PMC9721045 DOI: 10.1186/s13063-022-06906-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/03/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Given the large genetic heterogeneity in amyotrophic lateral sclerosis (ALS), it seems likely that genetic subgroups may benefit differently from treatment. An exploratory meta-analysis identified that patients homozygous for the C-allele at SNP rs12608932, a single nucleotide polymorphism in the gene UNC13A, had a statistically significant survival benefit when treated with lithium carbonate. We aim to confirm the efficacy of lithium carbonate on the time to death or respiratory insufficiency in patients with ALS homozygous for the C-allele at SNP rs12608932 in UNC13A. METHODS A randomized, group-sequential, event-driven, double-blind, placebo-controlled trial will be conducted in 15 sites across Europe and Australia. Patients will be genotyped for UNC13A; those homozygous for the C-allele at SNP rs12608932 will be eligible. Patients must have a diagnosis of ALS according to the revised El Escorial criteria, and a TRICALS risk-profile score between -6.0 and -2.0. An expected number of 1200 patients will be screened in order to enroll a target sample size of 171 patients. Patients will be randomly allocated in a 2:1 ratio to lithium carbonate or matching placebo, and treated for a maximum duration of 24 months. The primary endpoint is the time to death or respiratory insufficiency, whichever occurs first. Key secondary endpoints include functional decline, respiratory function, quality of life, tolerability, and safety. An interim analysis for futility and efficacy will be conducted after the occurrence of 41 events. DISCUSSION Lithium carbonate has been proven to be safe and well-tolerated in patients with ALS. Given the favorable safety profile, the potential benefits are considered to outweigh the burden and risks associated with study participation. This study may provide conclusive evidence about the life-prolonging potential of lithium carbonate in a genetic ALS subgroup. TRIAL REGISTRATION EudraCT number 2020-000579-19 . Registered on 29 March 2021.
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Affiliation(s)
- Sean W Willemse
- Department of Neurology, UMC Utrecht, Utrecht, The Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Radboud UMC, Nijmegen, The Netherlands
| | - Philip Van Damme
- 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
| | - Caroline Ingre
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Monica Povedano
- Functional Unit of Amyotrophic Lateral Sclerosis (UFELA), Service of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Naomi R Wray
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Marleen Gijzen
- Department of Genetics, UMC Utrecht, Utrecht, The Netherlands
| | | | - Koen C Demaegd
- Department of Neurology, UMC Utrecht, Utrecht, The Netherlands
| | | | | | | | - Adriano Chiò
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
- Neurology, AOU Città della Salute e della Scienza Hospital of Turin, Turin, Italy
| | - Philippe Corcia
- Centre Constitutif SLA, CHRU de Tours - Fédération des centres SLA Tours-Limoges, LitORALS, Tours, France
| | - Evy Reviers
- European Organization for Professionals and Patients with ALS (EUpALS) & ALS Liga Belgium, Leuven, Belgium
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, King's College London, Maurice Wohl Clinical Neuroscience Institute, London, UK
- Department of Neurology, King's College Hospital, London, UK
| | - Matthew C Kiernan
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | | | - Ruben P A van Eijk
- Department of Neurology, UMC Utrecht, Utrecht, The Netherlands.
- Biostatistics and Research Support, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands.
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15
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Song Y, Cheng H, Liu J, Kazuo S, Feng L, Wei Y, Zhang C, Gao Y. Effectiveness of herbal medicine on patients with amyotrophic lateral sclerosis: Analysis of the PRO-ACT data using propensity score matching. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 107:154461. [PMID: 36198223 DOI: 10.1016/j.phymed.2022.154461] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Patients with amyotrophic lateral sclerosis (ALS) have restricted pharmacotherapy options and thus resort to herbal medicines (HMs), despite limited and conflicting evidence. Therefore, use of HMs needs to be assessed in patients with ALS. PURPOSE This study aimed to evaluate the benefits of HMs in ALS and to describe the characteristics of HM users. STUDY DESIGN The correlation between HMs and prognosis was determined based on data obtained from the largest ALS database with high-quality clinical trials. Propensity score (PS) matching was used to address confounding and selection bias. METHODS In total, 321 and 231 HM users with at least a 4-week HM prescription were identified and PS-matched with non-HM users at a 1:1 ratio based on predefined confounders. Time-to-event models with censoring at 12 or 18 months were established for survival analyses. For evaluating activity limitation and respiratory function, 320 and 376 HM users were included, respectively, and analyzed using multivariate analysis of variance (MANOVA). RESULTS The profiles of 321 HM users indicated a better condition compared with that of non-HM users before PS-matching, including higher weight (median [IQR], 77.90 [21.8] kg vs. 74.00 [21.2] kg, p < 0.01), higher body mass index (26.00 [5.4] vs. 25.20 [5.8], p < 0.01), more percentage of limb onset (261 [81.3%] vs. 2366 [67.2%], p < 0.01), and slower progression (0.47 [0.5] vs. 0.51 [0.5], p = 0.03). HM did not significantly affect survival at 12 months (adjusted hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.49-1.03; log-rank p = 0.069), but it significantly prolonged survival at 18 months (adjusted HR 0.74, 95% CI 0.56-0.98; log-rank p = 0.038). After imputation of missing data, MANOVA revealed significant effectiveness of HMs in improving activity limitation (Pillai trace, 0.0195; p = 0.03). CONCLUSION PS-based methods eliminated baseline differences between HM and non-HM users. Overall, the use of HM to treat patients with ALS is favored based on their association with prolonged overall survival within 18 months and improved activity limitation.
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Affiliation(s)
- Yuebo Song
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Hao Cheng
- National Academy of Innovation Strategy, China Association for Science and Technology, Beijing 100038, China
| | - Jia Liu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Sugimoto Kazuo
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China; Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100010, China
| | - Luda Feng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Yufei Wei
- The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning 530022, China
| | - Chi Zhang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China.
| | - Ying Gao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China.
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16
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Feldman EL, Goutman SA, Petri S, Mazzini L, Savelieff MG, Shaw PJ, Sobue G. Amyotrophic lateral sclerosis. Lancet 2022; 400:1363-1380. [PMID: 36116464 PMCID: PMC10089700 DOI: 10.1016/s0140-6736(22)01272-7] [Citation(s) in RCA: 272] [Impact Index Per Article: 136.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/24/2022] [Accepted: 06/23/2022] [Indexed: 01/07/2023]
Abstract
Amyotrophic lateral sclerosis is a fatal CNS neurodegenerative disease. Despite intensive research, current management of amyotrophic lateral sclerosis remains suboptimal from diagnosis to prognosis. Recognition of the phenotypic heterogeneity of amyotrophic lateral sclerosis, global CNS dysfunction, genetic architecture, and development of novel diagnostic criteria is clarifying the spectrum of clinical presentation and facilitating diagnosis. Insights into the pathophysiology of amyotrophic lateral sclerosis, identification of disease biomarkers and modifiable risks, along with new predictive models, scales, and scoring systems, and a clinical trial pipeline of mechanism-based therapies, are changing the prognostic landscape. Although most recent advances have yet to translate into patient benefit, the idea of amyotrophic lateral sclerosis as a complex syndrome is already having tangible effects in the clinic. This Seminar will outline these insights and discuss the status of the management of amyotrophic lateral sclerosis for the general neurologist, along with future prospects that could improve care and outcomes for patients with amyotrophic lateral sclerosis.
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Affiliation(s)
- Eva L Feldman
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Stephen A Goutman
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Letizia Mazzini
- ALS Centre, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy; Department of Neurology, University of Piemonte Orientale, Novara, Italy
| | - Masha G Savelieff
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Gen Sobue
- Department of Neurology, Aichi Medical University, Nagakute, Aichi, Japan
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17
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Song Y, Jia Q, Guan X, Kazuo S, Liu J, Duan W, Feng L, Zhang C, Gao Y. Herbal medicine for amyotrophic lateral sclerosis: A systematic review and meta-analysis. Front Pharmacol 2022; 13:946548. [PMID: 36120351 PMCID: PMC9473725 DOI: 10.3389/fphar.2022.946548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/23/2022] [Indexed: 11/29/2022] Open
Abstract
Background: The effect of herbal medicine (HM) on amyotrophic lateral sclerosis (ALS) is controversial. Clinical trials investigating HMs continue; however, the use of HM is still questioned. We aimed to systematically review the literature pertaining to the effects and safety of HM in ALS. Methods: Randomised controlled trials (RCTs) that investigated the efficacy of HMs in ALS patients compared to any types of controls were identified. Nine databases and six registers were searched from their inception dates to 25 March 2022. Per the PRISMA guidelines, trials were identified and extracted. The risk of bias was evaluated using the Cochrane’s tool. Certainty of evidence was assessed as per the GRADE criteria. Forest plots were constructed to assess the effect size and corresponding 95% CIs using fixed-effect models, and random-effect models were employed when required. The primary outcome was the activity limitation measured by validated tools, such as the revised ALS Functional Rating Scale. Results: Twenty studies (N = 1,218) were eligible. Of these, only five studies were double-blinded, and two were placebo-controlled. Fourteen HMs (fifty-one single botanicals) were involved; Astragalus mongholicus Bunge, Atractylodes macrocephala Koidz., and Glycyrrhiza glabra L. were commonly used in nine, eight, and six trials, respectively. For delaying activity limitation, Jiweiling injection (MD, 2.84; 95% CI, 1.21 to 4.46; p = 0.0006) and Shenmai injection (SMD, 1.07; 0.69 to 1.45; p < 0.00001) were significantly more efficacious than Riluzole, but the evidence was low quality. For ameliorating motor neuron loss, Jiweiling injection [right abductor pollicis brevis (APB): MD, 32.42; 7.91 to 56.93; p = 0.01 and left APB: MD, 34.44; 12.85 to 56.03; p = 0.002] was favoured, but the evidence was very low quality. Nine studies reported one hundred and twenty-three adverse events, twenty-six of which occurred in the treatment groups and ninety-seven in the control groups. Conclusion: Very low to low quality of evidence suggests that HMs seem to produce superior treatment responses for ALS without increased risk of adverse events. Additional studies with homogeneous participants, reduced methodological issues, and more efficient outcome measures are required to provide confirmatory evidence. Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021277443.
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Affiliation(s)
- Yuebo Song
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
| | - Qiuyang Jia
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaorui Guan
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
| | - Sugimoto Kazuo
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jia Liu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
| | - Weisong Duan
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- Neurological Laboratory of Hebei Province, Shijiazhuang, China
| | - Luda Feng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
| | - Chi Zhang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- *Correspondence: Ying Gao, ; Chi Zhang,
| | - Ying Gao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
- *Correspondence: Ying Gao, ; Chi Zhang,
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18
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de Jongh AD, Braun N, Weber M, van Es MA, Masrori P, Veldink JH, van Damme P, van den Berg LH, van Eijk RPA. Characterising ALS disease progression according to El Escorial and Gold Coast criteria. J Neurol Neurosurg Psychiatry 2022; 93:865-870. [PMID: 35654584 DOI: 10.1136/jnnp-2022-328823] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/20/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The Gold Coast criteria (GCC) have been proposed as a means of selecting patients for amyotrophic lateral sclerosis (ALS) clinical trials. We aimed to characterise disease progression according to the GCC. METHODS Data from population-based ALS registries from the Netherlands and Belgium were analysed. The GCC additionally define ALS as lower motor neuron (LMN) dysfunction in ≥2 body regions without upper motor neuron dysfunction. Therefore, the revised El Escorial criteria (rEEC) were supplemented with a 'Gold Coast ALS' category for patients with only LMN dysfunction in ≥2 body regions. We assessed survival time, ALS Functional Rating Scale (ALSFRS-R) progression rates and between-patient variability per diagnostic category. RESULTS We included 5957 ALS patients, of whom 600 (10.1%) fulfilled the GCC but not the rEEC, and 95 (1.6%) fulfilled only the rEEC. ALSFRS-R progression rates were similar for the rEEC (0.84 points/month) and GCC (0.81 points/month) with similar variability (standard deviation of 0.59 vs. 0.60) and median survival time (17.8 vs.18.7 months). Survival time and average progression rates varied (p<0.001) between categories. Per category, however, there was considerable between-patient variability with progression rates ranging from: -2.10 to -0.14 (definite), -1.94 to -0.06 (probable), -2.10 to -0.02 (probable laboratory supported), -1.79 to -0.02 (possible) and -1.31 to 0.08 (Gold Coast). CONCLUSIONS The GCC broaden the definition of ALS, allowing more patients to participate in trials, while minimally impacting population heterogeneity. Given the large variability per diagnostic category, selecting only specific categories for trials may not result in a more homogeneous study population.
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Affiliation(s)
- Adriaan D de Jongh
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Nathalie Braun
- Neuromuscular Diseases Unit/ALS Clinic, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Markus Weber
- Neuromuscular Diseases Unit/ALS Clinic, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Michael A van Es
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Pegah Masrori
- 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
| | - Jan H Veldink
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Philip van Damme
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Leonard H van den Berg
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Ruben P A van Eijk
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands .,Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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19
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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: 10] [Impact Index Per Article: 5.0] [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.
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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
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20
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Joint modelling of endpoints can be used to answer various research questions in randomized clinical trials. J Clin Epidemiol 2022; 147:32-39. [DOI: 10.1016/j.jclinepi.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/27/2022] [Accepted: 03/21/2022] [Indexed: 11/20/2022]
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21
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Theunissen F, Flynn LL, Anderton RS, Akkari PA. Short structural variants as informative genetic markers for ALS disease risk and progression. BMC Med 2022; 20:11. [PMID: 35034660 PMCID: PMC8762977 DOI: 10.1186/s12916-021-02206-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/06/2021] [Indexed: 02/07/2023] Open
Abstract
There is considerable variability in disease progression for patients with amyotrophic lateral sclerosis (ALS) including the age of disease onset, site of disease onset, and survival time. There is growing evidence that short structural variations (SSVs) residing in frequently overlooked genomic regions can contribute to complex disease mechanisms and can explain, in part, the phenotypic variability in ALS patients. Here, we discuss SSVs recently characterized by our laboratory and how these discoveries integrate into the current literature on ALS, particularly in the context of application to future clinical trials. These markers may help to identify and differentiate patients for clinical trials that have a similar ALS disease mechanism(s), thereby reducing the impact of participant heterogeneity. As evidence accumulates for the genetic markers discovered in SQSTM1, SCAF4, and STMN2, we hope to improve the outcomes of future ALS clinical trials.
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Affiliation(s)
- Frances Theunissen
- Perron Institute for Neurological and Translational Science, First floor, RR block, QEII Medical Centre, 8 Verdun St, Nedlands, WA, 6009, Australia.
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Nedlands, WA, Australia.
| | - Loren L Flynn
- Perron Institute for Neurological and Translational Science, First floor, RR block, QEII Medical Centre, 8 Verdun St, Nedlands, WA, 6009, Australia
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Nedlands, WA, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Perth, WA, Australia
- Black Swan Pharmaceuticals, Wake Forrest, NC, USA
| | - Ryan S Anderton
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Nedlands, WA, Australia
- Faculty of Medicine, Nursing, Midwifery and Health Sciences, University of Notre Dame Australia, Fremantle, WA, 6160, Australia
| | - P Anthony Akkari
- Perron Institute for Neurological and Translational Science, First floor, RR block, QEII Medical Centre, 8 Verdun St, Nedlands, WA, 6009, Australia
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Nedlands, WA, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Perth, WA, Australia
- Black Swan Pharmaceuticals, Wake Forrest, NC, USA
- Division of Neurology, Duke University Medical Centre, Duke University, Durham, NC, USA
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22
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Petri S. Major research advances in amyotrophic lateral sclerosis in 2021. Lancet Neurol 2021; 21:14-15. [PMID: 34942124 DOI: 10.1016/s1474-4422(21)00420-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover 30625, Germany.
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