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Barp A, Gerardi F, Lizio A, Sansone VA, Lunetta C. Emerging Drugs for the Treatment of Amyotrophic Lateral Sclerosis: A Focus on Recent Phase 2 Trials. Expert Opin Emerg Drugs 2020; 25:145-164. [PMID: 32456491 DOI: 10.1080/14728214.2020.1769067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disease involving both upper and lower motor neurons and resulting in increasing disability and death 3-5 years after onset of symptoms. Over 40 large clinical trials for ALS have been negative, except for Riluzole that offers a modest survival benefit, and Edaravone that modestly reduces disease progression in patients with specific characteristics. Thus, the discovery of efficient disease modifying therapy is an urgent need. AREAS COVERED Although the cause of ALS remains unclear, many studies have demonstrated that neuroinflammation, proteinopathies, glutamate-induced excitotoxicity, microglial activation, oxidative stress, and mitochondrial dysfunction may play a key role in the pathogenesis. This review highlights recent discoveries relating to these diverse mechanisms and their implications for the development of therapy. Ongoing phase 2 clinical trials aimed to interfere with these pathophysiological mechanisms are discussed. EXPERT OPINION This review describes the challenges that the discovery of an efficient drug therapy faces and how these issues may be addressed. With the continuous advances coming from basic research, we provided possible suggestions that may be considered to improve performance of clinical trials and turn ALS research into a 'fertile ground' for drug development for this devastating disease.
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Affiliation(s)
- Andrea Barp
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy.,Dept. Biomedical Sciences of Health, University of Milan , Milan, Italy
| | | | - Andrea Lizio
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy
| | - Valeria Ada Sansone
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy.,Dept. Biomedical Sciences of Health, University of Milan , Milan, Italy
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5
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Devos D, Cabantchik ZI, Moreau C, Danel V, Mahoney-Sanchez L, Bouchaoui H, Gouel F, Rolland AS, Duce JA, Devedjian JC. Conservative iron chelation for neurodegenerative diseases such as Parkinson's disease and amyotrophic lateral sclerosis. J Neural Transm (Vienna) 2020; 127:189-203. [PMID: 31912279 DOI: 10.1007/s00702-019-02138-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/28/2019] [Indexed: 12/12/2022]
Abstract
Focal iron accumulation associated with brain iron dyshomeostasis is a pathological hallmark of various neurodegenerative diseases (NDD). The application of iron-sensitive sequences in magnetic resonance imaging has provided a useful tool to identify the underlying NDD pathology. In the three major NDD, degeneration occurs in central nervous system (CNS) regions associated with memory (Alzheimer's disease, AD), automaticity (Parkinson's disease, PD) and motor function (amyotrophic lateral sclerosis, ALS), all of which require a high oxygen demand for harnessing neuronal energy. In PD, a progressive degeneration of the substantia nigra pars compacta (SNc) is associated with the appearance of siderotic foci, largely caused by increased labile iron levels resulting from an imbalance between cell iron import, storage and export. At a molecular level, α-synuclein regulates dopamine and iron transport with PD-associated mutations in this protein causing functional disruption to these processes. Equally, in ALS, an early iron accumulation is present in neurons of the cortico-spinal motor pathway before neuropathology and secondary iron accumulation in microglia. High serum ferritin is an indicator of poor prognosis in ALS and the application of iron-sensitive sequences in magnetic resonance imaging has become a useful tool in identifying pathology. The molecular pathways that cascade down from such dyshomeostasis still remain to be fully elucidated but strong inroads have been made in recent years. Far from being a simple cause or consequence, it has recently been discovered that these alterations can trigger susceptibility to an iron-dependent cell-death pathway with unique lipoperoxidation signatures called ferroptosis. In turn, this has now provided insight into some key modulators of this cell-death pathway that could be therapeutic targets for the NDD. Interestingly, iron accumulation and ferroptosis are highly sensitive to iron chelation. However, whilst chelators that strongly scavenge intracellular iron protect against oxidative neuronal damage in mammalian models and are proven to be effective in treating systemic siderosis, these compounds are not clinically suitable due to the high risk of developing iatrogenic iron depletion and ensuing anaemia. Instead, a moderate iron chelation modality that conserves systemic iron offers a novel therapeutic strategy for neuroprotection. As demonstrated with the prototype chelator deferiprone, iron can be scavenged from labile iron complexes in the brain and transferred (conservatively) either to higher affinity acceptors in cells or extracellular transferrin. Promising preclinical and clinical proof of concept trials has led to several current large randomized clinical trials that aim to demonstrate the efficacy and safety of conservative iron chelation for NDD, notably in a long-term treatment regimen.
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Affiliation(s)
- David Devos
- Service de Pharmacologie Clinique et Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France.
- Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France.
- Département de Pharmacologie Médicale, Université Lille INSERM 1171, CHU de Lille, 59037, Lille, France.
| | - Z Ioav Cabantchik
- Della Pergola Chair, Alexander Silberman Institute of Life Sciences, Hebrew University, 91904, Jerusalem, Israel
| | - Caroline Moreau
- Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France
| | - Véronique Danel
- Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France
| | - Laura Mahoney-Sanchez
- Service de Pharmacologie Clinique et Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France
| | - Hind Bouchaoui
- Service de Pharmacologie Clinique et Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France
| | - Flore Gouel
- Service de Pharmacologie Clinique et Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France
| | - Anne-Sophie Rolland
- Service de Pharmacologie Clinique et Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France
| | - James A Duce
- The ALBORADA Drug Discovery Institute, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, UK
- Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Jean-Christophe Devedjian
- Service de Pharmacologie Clinique et Service de Neurologie NS-Park/FCRIN Network LICEND COEN Center Lille, Université de Lille, CHU de Lille, INSERM, UMRS_1171, Lille, France
- Université du Littoral Côte d'Opale-1, place de l'Yser, BP 72033, 59375, Dunkerque Cedex, France
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7
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Moreau C, Danel V, Devedjian JC, Grolez G, Timmerman K, Laloux C, Petrault M, Gouel F, Jonneaux A, Dutheil M, Lachaud C, Lopes R, Kuchcinski G, Auger F, Kyheng M, Duhamel A, Pérez T, Pradat PF, Blasco H, Veyrat-Durebex C, Corcia P, Oeckl P, Otto M, Dupuis L, Garçon G, Defebvre L, Cabantchik ZI, Duce J, Bordet R, Devos D. Could Conservative Iron Chelation Lead to Neuroprotection in Amyotrophic Lateral Sclerosis? Antioxid Redox Signal 2018; 29:742-748. [PMID: 29287521 PMCID: PMC6067092 DOI: 10.1089/ars.2017.7493] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Iron accumulation has been observed in mouse models and in both sporadic and familial forms of amyotrophic lateral sclerosis (ALS). Iron chelation could reduce iron accumulation and the related excess of oxidative stress in the motor pathways. However, classical iron chelation would induce systemic iron depletion. We assess the safety and efficacy of conservative iron chelation (i.e., chelation with low risk of iron depletion) in a murine preclinical model and pilot clinical trial. In Sod1G86R mice, deferiprone increased the mean life span compared with placebo. The safety was good, without anemia after 12 months of deferiprone in the 23 ALS patients enrolled in the clinical trial. The decreases in the ALS Functional Rating Scale and the body mass index were significantly smaller for the first 3 months of deferiprone treatment (30 mg/kg/day) than for the first treatment-free period. Iron levels in the cervical spinal cord, medulla oblongata, and motor cortex (according to magnetic resonance imaging), as well as cerebrospinal fluid levels of oxidative stress and neurofilament light chains were lower after deferiprone treatment. Our observation leads to the hypothesis that moderate iron chelation regimen that avoids changes in systemic iron levels may constitute a novel therapeutic modality of neuroprotection for ALS. Antioxid. Redox Signal. 29, 742-748.
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Affiliation(s)
- Caroline Moreau
- 1 Department of Neurology, ALS Center, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Véronique Danel
- 1 Department of Neurology, ALS Center, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Jean Christophe Devedjian
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Guillaume Grolez
- 1 Department of Neurology, ALS Center, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Kelly Timmerman
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Charlotte Laloux
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Maud Petrault
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Flore Gouel
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Aurélie Jonneaux
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Mary Dutheil
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Cédrick Lachaud
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Renaud Lopes
- 3 Department of Neuroradiology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Grégory Kuchcinski
- 3 Department of Neuroradiology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Florent Auger
- 4 Department of Preclinical Radiology, Lille University , INSERM UMRS_1171, LICEND COEN Center, Lille, France
| | - Maeva Kyheng
- 5 Department of Biostatistic, University of Lille , CHU Lille, EA 2694-Santé Publique: épidémiologie et qualité des soins, Lille, France
| | - Alain Duhamel
- 5 Department of Biostatistic, University of Lille , CHU Lille, EA 2694-Santé Publique: épidémiologie et qualité des soins, Lille, France
| | - Thierry Pérez
- 6 Department of Pneumology, Lille University, University Hospital Center , Lille, France
| | - Pierre François Pradat
- 7 Laboratoire d'Imagerie Biomédicale, Sorbonne Universités, UPMC University Paris 06 , CNRS, Inserm, Paris, France .,8 Département de Neurologie, AP-HP, Hôpital Pitié-Salpêtrière , Paris, France
| | - Hélène Blasco
- 9 Laboratoire de Biochimie, Université François Rabelais , INSERM U930, CHRU, Tours, France
| | | | - Philippe Corcia
- 9 Laboratoire de Biochimie, Université François Rabelais , INSERM U930, CHRU, Tours, France
| | - Patrick Oeckl
- 10 Department of Neurology, Center for Biomedical Research, Ulm University Hospital , Ulm, Germany
| | - Markus Otto
- 10 Department of Neurology, Center for Biomedical Research, Ulm University Hospital , Ulm, Germany
| | - Luc Dupuis
- 11 INSERM UMR-S1118, Faculté de Médecine de , Strasbourg, France
| | - Guillaume Garçon
- 12 EA4483 Department of Toxicology, CHU of Lille University , Lille, France
| | - Luc Defebvre
- 1 Department of Neurology, ALS Center, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - Z Ioav Cabantchik
- 13 Della Pergola Chair, Alexander Silberman Institute of Life Sciences, Hebrew University , Jerusalem, Israel
| | - James Duce
- 14 Alzheimer's Research UK Cambridge Drug Discovery Institute, University of Cambridge , Cambridge Biomedical Campus, Cambridge, United Kingdom .,15 The Florey Institute of Neuroscience and Mental Health, University of Melbourne , Parkville, Victoria, Australia
| | - Régis Bordet
- 2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
| | - David Devos
- 1 Department of Neurology, ALS Center, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France .,2 Department of Medical Pharmacology, Lille University, INSERM UMRS_1171, University Hospital Center , LICEND COEN Center, Lille, France
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