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Tian Hui Kwan A, Arfaie S, Therriault J, Rosa-Neto P, Gauthier S. Lessons Learnt from the Second Generation of Anti-Amyloid Monoclonal Antibodies Clinical Trials. Dement Geriatr Cogn Disord 2021; 49:334-348. [PMID: 33321511 DOI: 10.1159/000511506] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Alzheimer disease (AD) is a chronic neurodegenerative disorder with complex pathophysiology that affects over 50 million people worldwide. Most drug therapies, to date, have focused on targeting the amyloid-beta (Aβ) pathway, but clinical outcomes of anti-Aβ antibodies have been unsuccessful and unable to meet their primary endpoints. Similar trends have also been observed in treatments that target the tau pathway. SUMMARY This paper reviews recent anti-Aβ passive monotherapies, since Bapineuzumab, that have progressed to phase 3 clinical trials. Specifically, we discuss the 4 clinical trial programs of Solanezumab (targets Aβ monomers), Aducanumab (targets Aβ oligomers and plaques), Crenezumab (targets Aβ oligomers), and Gantenerumab (targets Aβ fibrils) which are all exogenous monoclonal antibodies. We conclude with potential reasons for why they have not met their primary endpoints and discuss lessons learnt from these trials. Key Message: Future disease-modifying trials (DMTs) for AD should be conducted in asymptomatic, Aβ-positive individuals. Moreover, potential additive and/or synergistic benefits focusing on anti-Aβ and anti-tau drug combinations merit further investigation.
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Affiliation(s)
- Angela Tian Hui Kwan
- Department of Chemical & Physical Sciences, University of Toronto, Toronto, Ontario, Canada.,Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Douglas Mental Health University Institute, McGill University, Montreal, Québec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
| | - Saman Arfaie
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Douglas Mental Health University Institute, McGill University, Montreal, Québec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada.,Faculty of Medicine, McGill University, Montreal, Québec, Canada.,Department of Molecular Cell Biology, University of California, Berkeley, California, USA
| | - Joseph Therriault
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Douglas Mental Health University Institute, McGill University, Montreal, Québec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada.,Department of Psychiatry, McGill University, Montreal, Québec, Canada
| | - Pedro Rosa-Neto
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Douglas Mental Health University Institute, McGill University, Montreal, Québec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada.,Department of Psychiatry, McGill University, Montreal, Québec, Canada
| | - Serge Gauthier
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Douglas Mental Health University Institute, McGill University, Montreal, Québec, Canada, .,Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada, .,Department of Psychiatry, McGill University, Montreal, Québec, Canada,
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Schwarz AJ, Sundell KL, Charil A, Case MG, Jaeger RK, Scott D, Bracoud L, Oh J, Suhy J, Pontecorvo MJ, Dickerson BC, Siemers ER. Magnetic resonance imaging measures of brain atrophy from the EXPEDITION3 trial in mild Alzheimer's disease. Alzheimers Dement (N Y) 2019; 5:328-37. [PMID: 31388559 DOI: 10.1016/j.trci.2019.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction Solanezumab is a humanized monoclonal antibody that preferentially binds to soluble amyloid β and promotes its clearance from the brain in preclinical studies. The objective of this study was to assess the effect of solanezumab in slowing global and anatomically localized brain atrophy as measured by volumetric magnetic resonance imaging (MRI). Methods In the EXPEDITION3 phase 3 trial, participants with mild Alzheimer's disease were randomized to receive intravenous infusions of either 400 mg of solanezumab or placebo every 4 weeks for 76 weeks. Volumetric MRI scans were acquired at baseline and at 80 weeks from 275 MRI facilities using a standardized imaging protocol. A subset of 1462 patients who completed both MRI and 14-item Alzheimer's Disease Assessment Scale–Cognitive Subscale assessments at both time points were selected for analysis. Longitudinal MRI volume changes were analyzed centrally by tensor-based morphometry with a standard FreeSurfer brain parcellation. Prespecified volumetric measures, including whole brain and ventricles, along with anatomically localized regions in the temporal, parietal, and frontal lobes were evaluated in those participants. Results Group-mean differences in brain atrophy rates were directionally consistent across a number of brain regions but small in magnitude (1.3–6.9% slowing) and not statistically significant when corrected for multiple comparisons. The annualized rates of change of the volumetric measures and the correlation of these changes with cognitive changes in placebo-treated subjects were similar to those reported previously. Discussion In the EXPEDITION3 trial, solanezumab did not significantly slow down rates of global or anatomically localized brain atrophy. Brain volume changes and their relationship to cognition were consistent with previous reports.
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Willis BA, Sundell K, Lachno DR, Ferguson-Sells LR, Case MG, Holdridge K, DeMattos RB, Raskin J, Siemers ER, Dean RA. Central pharmacodynamic activity of solanezumab in mild Alzheimer's disease dementia. Alzheimers Dement (N Y) 2018; 4:652-60. [PMID: 30511011 DOI: 10.1016/j.trci.2018.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction Solanezumab treatment was previously shown to significantly increase total (bound + unbound) cerebrospinal fluid (CSF) levels of amyloid β (Aβ)1–40 and Aβ1–42 in patients with mild to moderate Alzheimer's disease dementia yet did not produce meaningful cognitive effects. This analysis assessed solanezumab's central nervous system target engagement by evaluating changes in CSF total and free Aβ isoforms and their relationship with solanezumab exposure. Methods CSF Aβ isoform concentrations were measured in patients with mild Alzheimer's disease dementia from a pooled EXPEDITION + EXPEDITION2 population and from EXPEDITION3. CSF solanezumab concentrations were determined from EXPEDITION3. Results Solanezumab produced statistically significant increases in CSF total Aβ isoforms versus placebo, which correlated with CSF solanezumab concentration. Inconsistent effects on free Aβ isoforms were observed. Solanezumab penetration into the central nervous system was low. Discussion Solanezumab administration engaged the central molecular target, and molar ratio analyses demonstrated that higher exposures may further increase CSF total Aβ concentrations. Solanezumab increased cerebrospinal fluid levels of total amyloid β isoforms. Central pharmacodynamics of solanezumab were inconsistent. Penetration of solanezumab into the central nervous system was limited. Increased dosing may improve target engagement.
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Fleisher AS, Joshi AD, Sundell KL, Chen YF, Kollack-Walker S, Lu M, Chen S, Devous MD, Seibyl J, Marek K, Siemers ER, Mintun MA. Use of white matter reference regions for detection of change in florbetapir positron emission tomography from completed phase 3 solanezumab trials. Alzheimers Dement 2017; 13:1117-1124. [PMID: 28365320 DOI: 10.1016/j.jalz.2017.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 01/30/2017] [Accepted: 02/18/2017] [Indexed: 12/21/2022]
Abstract
INTRODUCTION We compared subject-specific white matter (SSWM) and whole cerebellum (CBL) reference regions for power to detect longitudinal change in amyloid positron emission tomography signal. METHODS Positive florbetapir positron emission tomography scans were analyzed from participants (66 placebo treated and 63 solanezumab treated) with mild dementia caused by Alzheimer's disease from the EXPEDITION and EXPEDITION2 studies. For comparison to CBL, a second normalization was performed on longitudinal data using an SSWM correction factor (SSWM normalization ratio [SSWMnr]). Analysis of covariance assessed baseline to 18-month change between treatment with solanezumab and placebo. Sample and effect size estimations provided magnitude of observed treatment changes. RESULTS Longitudinal percent change between placebo and solanezumab using CBL was not significant (P = .536) but was significant for SSWMnr (P = .042). Compared with CBL, SSWMnr technique increased the power to detect a treatment difference, more than tripling the effect size and reducing the sample size requirements by 85% to 90%. DISCUSSION Adjusting longitudinal standardized uptake value ratios with an SSWM reference region in these antiamyloid treatment trials increased mean change detection and decreased variance resulting in the substantial improvement in statistical power to detect change.
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Affiliation(s)
| | | | | | | | | | - Ming Lu
- Avid Radiopharmaceuticals, Philadelphia, PA, USA
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Kahle-Wrobleski K, Ye W, Henley D, Hake AM, Siemers E, Chen YF, Liu-Seifert H. Assessing quality of life in Alzheimer's disease: Implications for clinical trials. Alzheimers Dement (Amst) 2016; 6:82-90. [PMID: 28229126 PMCID: PMC5312555 DOI: 10.1016/j.dadm.2016.11.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Introduction Characterization of the quality of life (QOL) in Alzheimer's disease (AD) scale within the context of a clinical trial may inform its applicability in future trials. Methods Using data from 1322 patients enrolled in two phase-III studies (EXPEDITION 1 [NCT00905372] and 2 [NCT00904683]) of intravenous solanezumab in outpatients with mild AD dementia, correlations between patient- and caregiver-assessed QOL and between QOL and clinical outcome measures were examined. Longitudinal effects of solanezumab over 80 weeks were explored, controlling for patient and caregiver baseline characteristics. Results Caregivers rated patients' QOL worse than did patients themselves. Patients' QOL was correlated, albeit modestly, with clinical/health measures. Patients' QOL changed minimally over 80 weeks, although a treatment effect of solanezumab on QOL was detected. Discussion Further investigations are needed to determine the optimal measures with which to quantify and qualify QOL of patients with mild AD.
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Affiliation(s)
- Kristin Kahle-Wrobleski
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA; Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Wenyu Ye
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - David Henley
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA; Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ann Marie Hake
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA; Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric Siemers
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA; Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yun-Fei Chen
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Hong Liu-Seifert
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
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Chen YF, Ma X, Sundell K, Alaka K, Schuh K, Raskin J, Dean RA. Quantile regression to characterize solanezumab effects in Alzheimer's disease trials. Alzheimers Dement (N Y) 2016; 2:192-198. [PMID: 29067306 PMCID: PMC5651345 DOI: 10.1016/j.trci.2016.07.005] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Introduction In two solanezumab trials for mild-to-moderate Alzheimer's disease (AD) dementia, 27% of patients had biomarker confirmation of amyloid status. Of these, approximately 25% of mild patients and approximately 10% of moderate patients were amyloid negative and, as a group, did not exhibit clinical progression typical of AD. This post-hoc analysis describes a statistical surrogate for amyloid status. Methods Quantile regression was used to examine solanezumab treatment effects at fixed percentiles of varying degrees of clinical progression, with lowest percentiles (minimal progression atypical of AD) and higher percentiles acting as surrogates for amyloid negativity or positivity, respectively. Results In mild patients, solanezumab treatment effect was greater in higher percentiles of progression and less in lowest percentiles (AD-atypical). In moderate patients, solanezumab did not show effects across most percentiles. Discussion Results are compatible with design of the ongoing solanezumab EXPEDITION 3 trial that limits patients to those with mild AD dementia and evidence of amyloid pathology.
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Affiliation(s)
- Yun-Fei Chen
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Xiwen Ma
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Karen Sundell
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Karla Alaka
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Kory Schuh
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Joel Raskin
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Robert A Dean
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
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Siemers E, Holdridge KC, Sundell KL, Liu-Seifert H. Function and clinical meaningfulness of treatments for mild Alzheimer's disease. Alzheimers Dement (Amst) 2016; 2:105-12. [PMID: 27239541 DOI: 10.1016/j.dadm.2016.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction Effectiveness of Alzheimer's disease (AD) treatments is commonly evaluated with coprimary outcomes; cognition with function to ensure clinical meaningfulness of a cognitive effect. Methods We reviewed the literature for functional outcomes in mild AD or mild cognitive impairment (MCI) patients (distinct from combined mild-moderate/severe AD) treated with approved AD drugs. Cognitive and functional treatment differences in mild AD patients in solanezumab EXPEDITION/EXPEDITION2 studies were compared across time. Results Seven publications provided MCI/mild AD functional outcomes, one of which reported a significant functional treatment effect. Secondary analyses of EXPEDITION studies suggested a smaller functional effect of solanezumab relative to cognition. An increasing effect of solanezumab over 18 months was shown for cognition and function. Discussion Function as the sole measure to demonstrate clinical meaningfulness of cognitive effects in mild AD may have limitations. For disease-modifying treatments, point differences on cognitive and functional scales should be qualified with duration of treatment.
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Abstract
As the population of the world increases, there will be larger numbers of people with dementia and an emerging need for prompt diagnosis and treatment. Early dementia screening is the process by which a patient who might be in the prodromal phases of a dementing illness is determined as having, or not having, the hallmarks of a neurodegenerative condition. The concepts of mild cognitive impairment, or mild neurocognitive disorder, are useful in analyzing the patient in the prodromal phase of a dementing disease; however, the transformation to dementia may be as low as 10% per annum. The search for early dementia requires a comprehensive clinical evaluation, cognitive assessment, determination of functional status, corroborative history and imaging (including MRI, FDG-PET and maybe amyloid PET), cerebrospinal fluid (CSF) examination assaying Aβ1–42, T-τ and P-τ might also be helpful. Primary care physicians are fundamental in the screening process and are vital in initiating specialist investigation and treatment. Early dementia screening is especially important in an age where there is a search for disease modifying therapies, where there is mounting evidence that treatment, if given early, might influence the natural history—hence the need for cost-effective screening measures for early dementia.
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Affiliation(s)
- Peter K Panegyres
- Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth 6005, Western Australia, Australia.
| | - Renee Berry
- Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth 6005, Western Australia, Australia.
| | - Jennifer Burchell
- Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth 6005, Western Australia, Australia.
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Liu-Seifert H, Siemers E, Holdridge KC, Andersen SW, Lipkovich I, Carlson C, Sethuraman G, Hoog S, Hayduk R, Doody R, Aisen P. Delayed-start analysis: Mild Alzheimer's disease patients in solanezumab trials, 3.5 years. Alzheimers Dement (N Y) 2015; 1:111-121. [PMID: 29854931 PMCID: PMC5975050 DOI: 10.1016/j.trci.2015.06.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Solanezumab is an anti-amyloid monoclonal antibody in clinical testing for treatment of Alzheimer's disease (AD). Its mechanism suggests the possibility of slowing the progression of AD. METHODS A possible disease-modifying effect of solanezumab was assessed using a new statistical method including noninferiority testing. Performance differences were compared during the placebo-controlled period with performance differences after the placebo patients crossed over to solanezumab in the delayed-start period. RESULTS Noninferiority of the 14-item Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog14) and Alzheimer's Disease Cooperative Study Activities of Daily Living inventory instrumental items (ADCS-iADL) differences was met through 132 weeks, indicating that treatment differences observed in the placebo-controlled period remained, within a predefined margin, after the placebo group initiated solanezumab. Solanezumab was well tolerated, and no new safety concerns were identified. DISCUSSION The results of this secondary analysis show that the mild subgroup of solanezumab-treated patients who initiated treatment early, at the start of the placebo-controlled period, retained an advantage at most time points in the delayed-start period.
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Affiliation(s)
| | | | | | | | | | | | | | - Sharon Hoog
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Rachelle Doody
- Alzheimer's Disease and Memory Disorders Center, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Paul Aisen
- Alzheimer's Disease Cooperative Study, Department of Neurosciences, University of California at San Diego, San Diego, CA, USA
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Siemers ER, Sundell KL, Carlson C, Case M, Sethuraman G, Liu-Seifert H, Dowsett SA, Pontecorvo MJ, Dean RA, Demattos R. Phase 3 solanezumab trials: Secondary outcomes in mild Alzheimer's disease patients. Alzheimers Dement 2015; 12:110-120. [PMID: 26238576 DOI: 10.1016/j.jalz.2015.06.1893] [Citation(s) in RCA: 255] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 06/08/2015] [Accepted: 06/17/2015] [Indexed: 12/31/2022]
Abstract
INTRODUCTION EXPEDITION and EXPEDITION2 were identically designed placebo-controlled phase 3 studies assessing effects of solanezumab, an antiamyloid monoclonal antibody binding soluble amyloid-β peptide, on cognitive and functional decline over 80 weeks in patients with mild-to-moderate Alzheimer's disease (AD). Primary findings for both studies have been published. METHODS Secondary analyses of efficacy, biomarker, and safety endpoints in the pooled (EXPEDTION + EXPEDITION2) mild AD population were performed. RESULTS In the mild AD population, less cognitive and functional decline was observed with solanezumab (n = 659) versus placebo (n = 663), measured by Alzheimer's Disease Assessment Scale Cognitive subscale, Mini-Mental State Examination, and Alzheimer's Disease Cooperative Study-Activities of Daily Living functional scale Instrumental ADLs. Baseline-to-endpoint changes did not differ between treatment groups for Alzheimer's Disease Cooperative Study-Activities of Daily Living functional scale, basic items of the ADCS-ADL, and Clinical Dementia Rating Sum of Boxes. Plasma/cerebrospinal fluid biomarker findings indicated target engagement by solanezumab. Solanezumab demonstrated acceptable safety. Efficacy findings for the moderate AD population are also provided. DISCUSSION These findings describe solanezumab effects on efficacy/safety measures in a mild AD population. Another phase 3 study, EXPEDITION3, will investigate solanezumab's effects in a mild AD population.
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Abstract
The Alzheimer's Association International Conference (AAIC) was held in Washington, D.C. this year. It is the world's largest meeting of the dementia research community, connecting care providers, clinicians and investigators. The extent of efforts being made in the field of Alzheimer's research was demonstrated by the wide and varied program at the conference. This report focuses on some of the therapeutic highlights from the first two poster sessions.
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