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Guglieri M, Clemens PR, Perlman SJ, Smith EC, Horrocks I, Finkel RS, Mah JK, Deconinck N, Goemans N, Haberlova J, Straub V, Mengle-Gaw LJ, Schwartz BD, Harper AD, Shieh PB, De Waele L, Castro D, Yang ML, Ryan MM, McDonald CM, Tulinius M, Webster R, McMillan HJ, Kuntz NL, Rao VK, Baranello G, Spinty S, Childs AM, Sbrocchi AM, Selby KA, Monduy M, Nevo Y, Vilchez-Padilla JJ, Nascimento-Osorio A, Niks EH, de Groot IJM, Katsalouli M, James MK, van den Anker J, Damsker JM, Ahmet A, Ward LM, Jaros M, Shale P, Dang UJ, Hoffman EP. Efficacy and Safety of Vamorolone vs Placebo and Prednisone Among Boys With Duchenne Muscular Dystrophy: A Randomized Clinical Trial. JAMA Neurol 2022; 79:1005-1014. [PMID: 36036925 PMCID: PMC9425287 DOI: 10.1001/jamaneurol.2022.2480] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Question For steroidal anti-inflammatory drugs, can efficacy be retained while safety concerns are reduced among boys with Duchenne muscular dystrophy (DMD) with the novel partial receptor agonist vamorolone? Findings A randomized, double-blind, placebo- and prednisone-controlled trial of vamorolone (2 dose groups) was carried out in 121 patients with DMD. The trial met the primary (time to stand velocity after 24 weeks for vamorolone, 6 mg/kg per day vs placebo) and first 4 sequential secondary motor function end points; vamorolone showed loss of bone morbidities compared with prednisone, with no stunting of growth and no deleterious changes in bone biomarkers. Meaning This study found that vamorolone, a dissociative steroidal anti-inflammatory, was able to reduce bone morbidities while retaining efficacy. Importance Corticosteroidal anti-inflammatory drugs are widely prescribed but long-term use shows adverse effects that detract from patient quality of life. Objective To determine if vamorolone, a structurally unique dissociative steroidal anti-inflammatory drug, is able to retain efficacy while reducing safety concerns with use in Duchenne muscular dystrophy (DMD). Design, Setting, and Participants Randomized, double-blind, placebo- and prednisone-controlled 24-week clinical trial, conducted from June 29, 2018, to February 24, 2021, with 24 weeks of follow-up. This was a multicenter study (33 referral centers in 11 countries) and included boys 4 to younger than 7 years of age with genetically confirmed DMD not previously treated with corticosteroids. Interventions The study included 4 groups: placebo; prednisone, 0.75 mg/kg per day; vamorolone, 2 mg/kg per day; and vamorolone, 6 mg/kg per day. Main Outcomes and Measures Study outcomes monitored (1) efficacy, which included motor outcomes (primary: time to stand from supine velocity in the vamorolone, 6 mg/kg per day, group vs placebo; secondary: time to stand from supine velocity [vamorolone, 2 mg/kg per day], 6-minute walk distance, time to run/walk 10 m [vamorolone, 2 and 6 mg/kg per day]; exploratory: NorthStar Ambulatory Assessment, time to climb 4 stairs) and (2) safety, which included growth, bone biomarkers, and a corticotropin (ACTH)–challenge test. Results Among the 133 boys with DMD enrolled in the study (mean [SD] age, 5.4 [0.9] years), 121 were randomly assigned to treatment groups, and 114 completed the 24-week treatment period. The trial met the primary end point for change from baseline to week 24 time to stand velocity for vamorolone, 6 mg/kg per day (least-squares mean [SE] velocity, 0.05 [0.01] m/s vs placebo −0.01 [0.01] m/s; 95% CI, 0.02-0.10; P = .002) and the first 4 sequential secondary end points: time to stand velocity, vamorolone, 2 mg/kg per day, vs placebo; 6-minute walk test, vamorolone, 6 mg/kg per day, vs placebo; 6-minute walk test, vamorolone, 2 mg/kg per day, vs placebo; and time to run/walk 10 m velocity, vamorolone, 6 mg/kg per day, vs placebo. Height percentile declined in prednisone-treated (not vamorolone-treated) participants (change from baseline [SD]: prednisone, −1.88 [8.81] percentile vs vamorolone, 6 mg/kg per day, +3.86 [6.16] percentile; P = .02). Bone turnover markers declined with prednisone but not with vamorolone. Boys with DMD at baseline showed low ACTH-stimulated cortisol and high incidence of adrenal insufficiency. All 3 treatment groups led to increased adrenal insufficiency. Conclusions and Relevance In this pivotal randomized clinical trial, vamorolone was shown to be effective and safe in the treatment of boys with DMD over a 24-week treatment period. Vamorolone may be a safer alternative than prednisone in this disease, in which long-term corticosteroid use is the standard of care. Trial Registration ClinicalTrials.gov Identifier: NCT03439670
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Affiliation(s)
- Michela Guglieri
- John Walton Muscular Dystrophy Research Centre, Newcastle Hospitals NHS Foundation Trust and Newcastle University, Newcastle, United Kingdom
| | - Paula R Clemens
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Edward C Smith
- Duke University School of Medicine, Durham, North Carolina
| | - Iain Horrocks
- Royal Hospital for Children, Glasgow, United Kingdom
| | - Richard S Finkel
- Nemours Children's Hospital, Orlando, Florida.,St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jean K Mah
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Nathalie Goemans
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Paediatric Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Jana Haberlova
- Neuromuscular Centre, Department of Pediatric Neurology, Motol University Hospital, 2nd Medical School, Charles University, Prague, Czech Republic
| | - Volker Straub
- John Walton Muscular Dystrophy Research Centre, Newcastle Hospitals NHS Foundation Trust and Newcastle University, Newcastle, United Kingdom
| | | | | | - Amy D Harper
- Richmond Children's Hospital, Richmond, Virginia
| | | | - Liesbeth De Waele
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Paediatric Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | - Michelle L Yang
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Monique M Ryan
- The Royal Children's Hospital, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Mar Tulinius
- Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Richard Webster
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Nancy L Kuntz
- Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Vashmi K Rao
- Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Giovanni Baranello
- The Dubowitz Neuromuscular Centre, National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street Institute of Child Health University College London, London, United Kingdom
| | - Stefan Spinty
- Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | | | | | - Kathryn A Selby
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | | | - Yoram Nevo
- Schneider Children's Medical Center, Tel Aviv University, Tel Aviv, Israel
| | | | - Andres Nascimento-Osorio
- Neuropaediatrics Department, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Barcelona, Spain
| | - Erik H Niks
- Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Meredith K James
- John Walton Muscular Dystrophy Research Centre, Newcastle Hospitals NHS Foundation Trust and Newcastle University, Newcastle, United Kingdom
| | - Johannes van den Anker
- ReveraGen BioPharma, Rockville, Maryland.,Children's National Medical Center, Washington, DC
| | | | - Alexandra Ahmet
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Leanne M Ward
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | | | | | | | - Eric P Hoffman
- ReveraGen BioPharma, Rockville, Maryland.,Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences Binghamton University-State University of New York, Binghamton
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Statland JM, Campbell C, Desai U, Karam C, Díaz-Manera J, Guptill JT, Korngut L, Genge A, Tawil RN, Elman L, Joyce NC, Wagner KR, Manousakis G, Amato AA, Butterfield RJ, Shieh PB, Wicklund M, Gamez J, Bodkin C, Pestronk A, Weihl CC, Vilchez-Padilla JJ, Johnson NE, Mathews KD, Miller B, Leneus A, Fowler M, van de Rijn M, Attie KM. Randomized phase 2 study of ACE-083, a muscle-promoting agent, in facioscapulohumeral muscular dystrophy. Muscle Nerve 2022; 66:50-62. [PMID: 35428982 PMCID: PMC9321022 DOI: 10.1002/mus.27558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 12/21/2022]
Abstract
Introduction/Aims Facioscapulohumeral muscular dystrophy (FSHD) is a slowly progressive muscular dystrophy without approved therapies. In this study we evaluated whether locally acting ACE‐083 could safely increase muscle volume and improve functional outcomes in adults with FSHD. Methods Participants were at least 18 years old and had FSHD1/FSHD2. Part 1 was open label, ascending dose, assessing safety and tolerability (primary objective). Part 2 was randomized, double‐blind for 6 months, evaluating ACE‐083240 mg/muscle vs placebo injected bilaterally every 3 weeks in the biceps brachii (BB) or tibialis anterior (TA) muscles, followed by 6 months of open label. Magnetic resonance imaging measures included total muscle volume (TMV; primary objective), fat fraction (FF), and contractile muscle volume (CMV). Functional measures included 6‐minute walk test, 10‐meter walk/run, and 4‐stair climb (TA group), and performance of upper limb midlevel/elbow score (BB group). Strength, patient‐reported outcomes (PROs), and safety were also evaluated. Results Parts 1 and 2 enrolled 37 and 58 participants, respectively. Among 55 participants evaluable in Part 2, the least‐squares mean (90% confidence interval, analysis of covariance) treatment difference for TMV was 16.4% (9.8%‐23.0%) in the BB group (P < .0001) and 9.5% (3.2%‐15.9%) in the TA group (P = .01). CMV increased significantly in the BB and TA groups and FF decreased in the TA group. There were no consistent improvements in functional or PRO measures in either group. The most common adverse events were mild or moderate injection‐site reactions. Discussion Significant increases in TMV with ACE‐083 vs placebo did not result in consistent functional or PRO improvements with up to 12 months of treatment.
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Affiliation(s)
- Jeffrey M Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Craig Campbell
- Department of Pediatrics and Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada
| | - Urvi Desai
- Carolinas MDA Care Center, Atrium Health, Charlotte, North Carolina, USA
| | - Chafic Karam
- Neuromuscular Division, Oregon Health & Science University, Portland, Oregon, USA
| | - Jordi Díaz-Manera
- Neuromuscular Diseases Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain.,John Walton Muscular Dystrophy Research Centre, Newcastle University Translational and Clinical Research Institute, Newcastle, UK
| | - Jeffrey T Guptill
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Angela Genge
- Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Rabi N Tawil
- University of Rochester School of Medicine, Rochester, New York, USA
| | - Lauren Elman
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nanette C Joyce
- University of California Davis Medical Center, Davis, California, USA
| | - Kathryn R Wagner
- Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Georgios Manousakis
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Russell J Butterfield
- Departments of Neurology and Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Perry B Shieh
- University of California Los Angeles, Los Angeles, California, USA
| | | | - Josep Gamez
- Department of Medicine, GMA Clinic, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD) and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cynthia Bodkin
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alan Pestronk
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Conrad C Weihl
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Juan J Vilchez-Padilla
- Hospital UIP La Fe, Neuromuscular Reference Centre, Valencia, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain
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