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Lee AJB, Kittel TE, Kim RB, Bach TN, Zhang T, Mitchell CS. Comparing therapeutic modulators of the SOD1 G93A Amyotrophic Lateral Sclerosis mouse pathophysiology. Front Neurosci 2023; 16:1111763. [PMID: 36741054 PMCID: PMC9893287 DOI: 10.3389/fnins.2022.1111763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/28/2022] [Indexed: 01/20/2023] Open
Abstract
Introduction Amyotrophic Lateral Sclerosis (ALS) is a paralyzing, multifactorial neurodegenerative disease with limited therapeutics and no known cure. The study goal was to determine which pathophysiological treatment targets appear most beneficial. Methods A big data approach was used to analyze high copy SOD1 G93A experimental data. The secondary data set comprised 227 published studies and 4,296 data points. Treatments were classified by pathophysiological target: apoptosis, axonal transport, cellular chemistry, energetics, neuron excitability, inflammation, oxidative stress, proteomics, or systemic function. Outcome assessment modalities included onset delay, health status (rotarod performance, body weight, grip strength), and survival duration. Pairwise statistical analysis (two-tailed t-test with Bonferroni correction) of normalized fold change (treatment/control) assessed significant differences in treatment efficacy. Cohen's d quantified pathophysiological treatment category effect size compared to "all" (e.g., all pathophysiological treatment categories combined). Results Inflammation treatments were best at delaying onset (d = 0.42, p > 0.05). Oxidative stress treatments were significantly better for prolonging survival duration (d = 0.18, p < 0.05). Excitability treatments were significantly better for prolonging overall health status (d = 0.22, p < 0.05). However, the absolute best pathophysiological treatment category for prolonging health status varied with disease progression: oxidative stress was best for pre-onset health (d = 0.18, p > 0.05); excitability was best for prolonging function near onset (d = 0.34, p < 0.05); inflammation was best for prolonging post-onset function (d = 0.24, p > 0.05); and apoptosis was best for prolonging end-stage function (d = 0.49, p > 0.05). Finally, combination treatments simultaneously targeting multiple pathophysiological categories (e.g., polytherapy) performed significantly (p < 0.05) better than monotherapies at end-stage. Discussion In summary, the most effective pathophysiological treatments change as function of assessment modality and disease progression. Shifting pathophysiological treatment category efficacy with disease progression supports the homeostatic instability theory of ALS disease progression.
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Affiliation(s)
- Albert J. B. Lee
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
- Center for Machine Learning, Georgia Institute of Technology, Atlanta, GA, United States
| | - Tyler E. Kittel
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
| | - Renaid B. Kim
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
- University of Michigan Medical School, Ann Arbor, MI, United States
| | - Thao-Nguyen Bach
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
- University of Texas at Dallas, Dallas, TX, United States
| | - Tian Zhang
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
| | - Cassie S. Mitchell
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
- Center for Machine Learning, Georgia Institute of Technology, Atlanta, GA, United States
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Glial Cells-The Strategic Targets in Amyotrophic Lateral Sclerosis Treatment. J Clin Med 2020; 9:jcm9010261. [PMID: 31963681 PMCID: PMC7020059 DOI: 10.3390/jcm9010261] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurological disease, which is characterized by the degeneration of motor neurons in the motor cortex and the spinal cord and subsequently by muscle atrophy. To date, numerous gene mutations have been linked to both sporadic and familial ALS, but the effort of many experimental groups to develop a suitable therapy has not, as of yet, proven successful. The original focus was on the degenerating motor neurons, when researchers tried to understand the pathological mechanisms that cause their slow death. However, it was soon discovered that ALS is a complicated and diverse pathology, where not only neurons, but also other cell types, play a crucial role via the so-called non-cell autonomous effect, which strongly deteriorates neuronal conditions. Subsequently, variable glia-based in vitro and in vivo models of ALS were established and used for brand-new experimental and clinical approaches. Such a shift towards glia soon bore its fruit in the form of several clinical studies, which more or less successfully tried to ward the unfavourable prognosis of ALS progression off. In this review, we aimed to summarize current knowledge regarding the involvement of each glial cell type in the progression of ALS, currently available treatments, and to provide an overview of diverse clinical trials covering pharmacological approaches, gene, and cell therapies.
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Hobson EV, Baird WO, Bradburn M, Cooper C, Mawson S, Quinn A, Shaw PJ, Walsh T, McDermott CJ. Using telehealth in motor neuron disease to increase access to specialist multidisciplinary care: a UK-based pilot and feasibility study. BMJ Open 2019; 9:e028525. [PMID: 31640993 PMCID: PMC6830633 DOI: 10.1136/bmjopen-2018-028525] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Care of patients with motor neuron disease (MND) in a specialist, multidisciplinary clinic is associated with improved survival, but access is not universal. We wanted to pilot and establish the feasibility of a definitive trial of a novel telehealth system (Telehealth in Motor neuron disease, TiM) in patients with MND. DESIGN An 18-month, single-centre, mixed-methods, randomised, controlled pilot and feasibility study. INTERVENTION TiM telehealth plus usual care versus usual care. SETTING A specialist MND care centre in the UK. PARTICIPANTS Patients with MND and their primary informal carers. PRIMARY AND SECONDARY OUTCOME MEASURES Recruitment, retention and data collection rates, clinical outcomes including participant quality of life and anxiety and depression. RESULTS Recruitment achieved the target of 40 patients and 37 carers. Participant characteristics reflected those attending the specialist clinic and included those with severe disability and those with limited experience of technology. Retention and data collection was good. Eighty per cent of patients and 82% of carer participants reported outcome measures were completed at 6 months. Using a longitudinal analysis with repeated measures of quality of life (QoL), a sample size of 131 per arm is recommended in a definitive trial. The methods and intervention were acceptable to participants who were highly motivated to participate to research. The low burden of participation and accessibility of the intervention meant barriers to participation were minimal. However, the study highlighted difficulties assessing the associated costs of the intervention, the challenge of recruitment in such a rare disease and the difficulties of producing rigorous evidence of impact in such a complex intervention. CONCLUSION A definitive trial of TiM is feasible but challenging. The complexity of the intervention and heterogeneity of the patient population means that a randomised controlled trial may not be the best way to evaluate the further development and implementation of the TiM. TRIAL REGISTRATION NUMBER ISRCTN26675465.
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Affiliation(s)
- Esther V Hobson
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Wendy O Baird
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Susan Mawson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ann Quinn
- Sheffield Motor Neurone Disease Association Research Advisory Group, Sheffield, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Theresa Walsh
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christopher J McDermott
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Babu S, Macklin EA, Jackson KE, Simpson E, Mahoney K, Yu H, Walker J, Simmons Z, David WS, Barkhaus PE, Simionescu L, Dimachkie MM, Pestronk A, Salameh JS, Weiss MD, Brooks BR, Schoenfeld D, Shefner J, Aggarwal S, Cudkowicz ME, Atassi N. Selection design phase II trial of high dosages of tamoxifen and creatine in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2019; 21:15-23. [DOI: 10.1080/21678421.2019.1672750] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Suma Babu
- Department of Neurology, Sean M Healey & AMG Center for ALS at Massachusetts General Hospital, Neurological Clinical Research Institute, Boston, MA, USA,
| | - Eric A. Macklin
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,
| | - Katherine E. Jackson
- Office of the Prescription Drug Monitoring Program, Maryland Department of Health, Baltimore, MD, USA,
| | - Elizabeth Simpson
- McCance Center for Brain Health at Massachusetts General Hospital, Boston, MA, USA,
| | - Katy Mahoney
- Department of Neurology, Sean M Healey & AMG Center for ALS at Massachusetts General Hospital, Neurological Clinical Research Institute, Boston, MA, USA,
| | - Hong Yu
- Department of Neurology, Sean M Healey & AMG Center for ALS at Massachusetts General Hospital, Neurological Clinical Research Institute, Boston, MA, USA,
| | - Jason Walker
- Department of Neurology, Sean M Healey & AMG Center for ALS at Massachusetts General Hospital, Neurological Clinical Research Institute, Boston, MA, USA,
| | | | - William S. David
- Department of Neurology, Sean M Healey & AMG Center for ALS at Massachusetts General Hospital, Neurological Clinical Research Institute, Boston, MA, USA,
| | | | | | | | - Alan Pestronk
- Washington University School of Medicine, St. Louis, MO, USA,
| | | | | | - Benjamin Rix Brooks
- Atrium Health Neurosciences Institute, Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte, NC, USA, and
| | - David Schoenfeld
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,
| | - Jeremy Shefner
- Barrow Neurological Institute and University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Swati Aggarwal
- Department of Neurology, Sean M Healey & AMG Center for ALS at Massachusetts General Hospital, Neurological Clinical Research Institute, Boston, MA, USA,
| | - Merit E. Cudkowicz
- Department of Neurology, Sean M Healey & AMG Center for ALS at Massachusetts General Hospital, Neurological Clinical Research Institute, Boston, MA, USA,
| | - Nazem Atassi
- Department of Neurology, Sean M Healey & AMG Center for ALS at Massachusetts General Hospital, Neurological Clinical Research Institute, Boston, MA, USA,
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Karanevich AG, Weisbrod LJ, Jawdat O, Barohn RJ, Gajewski BJ, He J, Statland JM. Using automated electronic medical record data extraction to model ALS survival and progression. BMC Neurol 2018; 18:205. [PMID: 30547800 PMCID: PMC6295028 DOI: 10.1186/s12883-018-1208-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 11/29/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To assess the feasibility of using automated capture of Electronic Medical Record (EMR) data to build predictive models for amyotrophic lateral sclerosis (ALS) outcomes. METHODS We used an Informatics for Integrating Biology and the Bedside search discovery tool to identify and extract data from 354 ALS patients from the University of Kansas Medical Center EMR. The completeness and integrity of the data extraction were verified by manual chart review. A linear mixed model was used to model disease progression. Cox proportional hazards models were used to investigate the effects of BMI, gender, and age on survival. RESULTS Data extracted from the EMR was sufficient to create simple models of disease progression and survival. Several key variables of interest were unavailable without including a manual chart review. The average ALS Functional Rating Scale - Revised (ALSFRS-R) baseline score at first clinical visit was 34.08, and average decline was - 0.64 per month. Median survival was 27 months after first visit. Higher baseline ALSFRS-R score and BMI were associated with improved survival, higher baseline age was associated with decreased survival. CONCLUSIONS This study serves to show that EMR-captured data can be extracted and used to track outcomes in an ALS clinic setting, potentially important for post-marketing research of new drugs, or as historical controls for future studies. However, as automated EMR-based data extraction becomes more widely used there will be a need to standardize ALS data elements and clinical forms for data capture so data can be pooled across academic centers.
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Affiliation(s)
- Alex G. Karanevich
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, USA
- EMB Statistical Solutions, LLC, Overland Park, KS 66210 USA
| | - Luke J. Weisbrod
- School of Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Omar Jawdat
- Department of Neurology, University of Kansas Medical Center, Kansas City, USA
| | - Richard J. Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, USA
| | - Byron J. Gajewski
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, USA
| | - Jianghua He
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, USA
| | - Jeffrey M. Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, USA
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Statland JM, Moore D, Wang Y, Walsh M, Mozaffar T, Elman L, Nations SP, Mitsumoto H, Fernandes JA, Saperstein D, Hayat G, Herbelin L, Karam C, Katz J, Wilkins HM, Agbas A, Swerdlow RH, Santella RM, Dimachkie MM, Barohn RJ. Rasagiline for amyotrophic lateral sclerosis: A randomized, controlled trial. Muscle Nerve 2018; 59:201-207. [PMID: 30192007 PMCID: PMC6545236 DOI: 10.1002/mus.26335] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Rasagiline is a monoamine oxidase B (MAO-B) inhibitor with possible neuroprotective effects in patients with amyotrophic lateral sclerosis (ALS). METHODS We performed a randomized, double-blind, placebo-controlled trial of 80 ALS participants with enrichment of the placebo group with historical controls (n = 177) at 10 centers in the United States. Participants were randomized in a 3:1 ratio to 2 mg/day rasagiline or placebo. The primary outcome was average slope of decline on the ALS Functional Rating Scale-Revised (ALSFRS-R). Secondary measures included slow vital capacity, survival, mitochondrial and molecular biomarkers, and adverse-event reporting. RESULTS There was no difference in the average 12-month ALSFRS-R slope between rasagiline and the mixed placebo and historical control cohorts. Rasagiline did not show signs of drug-target engagement in urine and blood biomarkers. Rasagiline was well tolerated with no serious adverse events. DISCUSSION Rasagiline did not alter disease progression compared with controls over 12 months of treatment. Muscle Nerve 59:201-207, 2019.
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Affiliation(s)
- Jeffrey M Statland
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 2012, Kansas City, Kansas, 66160, USA
| | - Dan Moore
- The Forbes Norris MDA/ALS Research Center, California Pacific Medical Center, San Francisco, California, USA
| | - Yunxia Wang
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 2012, Kansas City, Kansas, 66160, USA
| | - Maureen Walsh
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 2012, Kansas City, Kansas, 66160, USA
| | - Tahseen Mozaffar
- Department of Neurology, University of California, Irvine, Irvine, California, USA
| | - Lauren Elman
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennslyvania, USA
| | - Sharon P Nations
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hiroshi Mitsumoto
- Department of Neurology, Columbia University, New York, New York, USA
| | - J Americo Fernandes
- Department of Neurology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Ghazala Hayat
- Department of Neurology, St. Louis University, St. Louis, Missouri, USA
| | - Laura Herbelin
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 2012, Kansas City, Kansas, 66160, USA
| | - Chafic Karam
- Department of Neurology, Oregon Health and Science University, Portland, Oregon, USA
| | - Jonathan Katz
- The Forbes Norris MDA/ALS Research Center, California Pacific Medical Center, San Francisco, California, USA
| | - Heather M Wilkins
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 2012, Kansas City, Kansas, 66160, USA
| | - Abdulbaki Agbas
- Department of Biosciences, Kansas City University of Medicine and Bioscience, Kansas City, Missouri, USA
| | - Russell H Swerdlow
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 2012, Kansas City, Kansas, 66160, USA
| | - Regina M Santella
- Department of Neurology, Columbia University, New York, New York, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 2012, Kansas City, Kansas, 66160, USA
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 2012, Kansas City, Kansas, 66160, USA
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van Eijk RPA, Nikolakopoulos S, Ferguson TA, Liu D, Eijkemans MJC, van den Berg LH. Increasing the efficiency of clinical trials in neurodegenerative disorders using group sequential trial designs. J Clin Epidemiol 2018; 98:80-88. [PMID: 29486281 DOI: 10.1016/j.jclinepi.2018.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/21/2017] [Accepted: 02/16/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Clinical trials in neurodegenerative disorders are facing high futility rates and rising development costs. We aim to review and exemplify the value of group sequential trial designs (i.e., designs with one or more prospectively planned interim analyses) within the field of amyotrophic lateral sclerosis. STUDY DESIGN AND SETTING We reviewed the literature to identify sequentially conducted trials. Subsequently, we reanalyzed the dexpramipexole trial (EMPOWER), a classically designed and conducted trial involving 942 participants, by sequentially monitoring the functional questionnaire and survival endpoint. Finally, we simulated the performance of the sequential methodology under different treatment effects. RESULTS Only six (12%) randomized, placebo-controlled trials incorporated stopping rules for both futility and superiority. Despite its high enrollment rate, sequential reanalysis of the EMPOWER study reduced the total trial duration with 140 days (23.4%, 95% confidence interval [CI] 13.2-34.4%), the number of follow-ups with 2,688 visits (23.6%, 95% CI 11.3-38.6%), and the total drug exposure time with 73,377 days (20.6%, 95% CI 9.8-35.9%). The functional questionnaire considerably increased the heterogeneity in the test statistics, which may negatively affect sequential monitoring. CONCLUSION Group sequential trials can result in important reductions in the trial duration, which could make clinical trials more ethical by reducing the patients' exposure to noneffective treatments or by limiting their time on placebo.
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Affiliation(s)
- Ruben P A van Eijk
- Department of Neurology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Stavros Nikolakopoulos
- Department of Biostatistics and Research Support, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - Marinus J C Eijkemans
- Department of Biostatistics and Research Support, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Sakuma K, Yamaguchi A. Drugs of Muscle Wasting and Their Therapeutic Targets. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1088:463-481. [PMID: 30390265 DOI: 10.1007/978-981-13-1435-3_21] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Muscle wasting and weakness such as cachexia, atrophy, and sarcopenia are characterized by marked decreases in the protein content, myonuclear number, muscle fiber size, and muscle strength. This chapter focuses on the recent advances of pharmacological approach for attenuating muscle wasting.A myostatin-inhibiting approach is very intriguing to prevent sarcopenia but not muscular dystrophy in humans. Supplementation with ghrelin is also an important candidate to combat sarcopenia as well as cachexia. Treatment with soy isoflavone, trichostatin A (TSA), and cyclooxygenase 2 (Cox2) inhibitors seems to be effective modulators attenuating muscle wasting, although further systematic research is needed on this treatment in particular concerning side effects.
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Affiliation(s)
- Kunihiro Sakuma
- Institute for Liberal Arts, Environment and Society, Tokyo Institute of Technology, Tokyo, Japan.
| | - Akihiko Yamaguchi
- Department of Physical Therapy, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan
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Khalid SI, Ampie L, Kelly R, Ladha SS, Dardis C. Immune Modulation in the Treatment of Amyotrophic Lateral Sclerosis: A Review of Clinical Trials. Front Neurol 2017; 8:486. [PMID: 28993751 PMCID: PMC5622209 DOI: 10.3389/fneur.2017.00486] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/31/2017] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by the degeneration of motor neurons. Though many molecular and genetic causes are thought to serve as predisposing or disease propagating factors, the underlying pathogenesis of the disease is not known. Recent discoveries have demonstrated the presence of inflammation propagating substrates in the central nervous system of patients afflicted with ALS. Over the past decade, this hypothesis has incited an effort to better understand the role of the immune system in ALS and has led to the trial of several potential immune-modulating therapies. Here, we briefly review advances in the role of such therapies. The clinical trials discussed here are currently ongoing or have been concluded at the time of writing.
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Affiliation(s)
| | - Leonel Ampie
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD, United States.,Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA, United States.,Georgetown University School of Medicine, Washington, DC, United States
| | - Ryan Kelly
- Georgetown University School of Medicine, Washington, DC, United States
| | - Shafeeq S Ladha
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Christopher Dardis
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, United States
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Mohamed LA, Markandaiah S, Bonanno S, Pasinelli P, Trotti D. Blood-Brain Barrier Driven Pharmacoresistance in Amyotrophic Lateral Sclerosis and Challenges for Effective Drug Therapies. AAPS JOURNAL 2017; 19:1600-1614. [PMID: 28779378 DOI: 10.1208/s12248-017-0120-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/28/2017] [Indexed: 12/11/2022]
Abstract
The blood-brain barrier (BBB) is essential for proper neuronal function, homeostasis, and protection of the central nervous system (CNS) microenvironment from blood-borne pathogens and neurotoxins. The BBB is also an impediment for CNS penetration of drugs. In some neurologic conditions, such as epilepsy and brain tumors, overexpression of P-glycoprotein, an efflux transporter whose physiological function is to expel catabolites and xenobiotics from the CNS into the blood stream, has been reported. Recent studies reported that overexpression of P-glycoprotein and increase in its activity at the BBB drives a progressive resistance to CNS penetration and persistence of riluzole, the only drug approved thus far for treatment of amyotrophic lateral sclerosis (ALS), rapidly progressive and mostly fatal neurologic disease. This review will discuss the impact of transporter-mediated pharmacoresistance for ALS drug therapy and the potential therapeutic strategies to improve the outcome of ALS clinical trials and efficacy of current and future drug treatments.
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Affiliation(s)
- Loqman A Mohamed
- Jefferson Weinberg ALS Center, Vickie and Jack Farber Institute for Neuroscience, Department of Neuroscience, Thomas Jefferson University Hospitals, 900 Walnut Street, Philadelphia, Pennsylvania, 19107, USA.
| | - Shashirekha Markandaiah
- Jefferson Weinberg ALS Center, Vickie and Jack Farber Institute for Neuroscience, Department of Neuroscience, Thomas Jefferson University Hospitals, 900 Walnut Street, Philadelphia, Pennsylvania, 19107, USA
| | - Silvia Bonanno
- Jefferson Weinberg ALS Center, Vickie and Jack Farber Institute for Neuroscience, Department of Neuroscience, Thomas Jefferson University Hospitals, 900 Walnut Street, Philadelphia, Pennsylvania, 19107, USA
| | - Piera Pasinelli
- Jefferson Weinberg ALS Center, Vickie and Jack Farber Institute for Neuroscience, Department of Neuroscience, Thomas Jefferson University Hospitals, 900 Walnut Street, Philadelphia, Pennsylvania, 19107, USA
| | - Davide Trotti
- Jefferson Weinberg ALS Center, Vickie and Jack Farber Institute for Neuroscience, Department of Neuroscience, Thomas Jefferson University Hospitals, 900 Walnut Street, Philadelphia, Pennsylvania, 19107, USA
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Positron emission tomography in amyotrophic lateral sclerosis: Towards targeting of molecular pathological hallmarks. Eur J Nucl Med Mol Imaging 2016; 44:533-547. [DOI: 10.1007/s00259-016-3587-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/23/2016] [Indexed: 12/18/2022]
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Blasco H, Patin F, Andres CR, Corcia P, Gordon PH. Amyotrophic Lateral Sclerosis, 2016: existing therapies and the ongoing search for neuroprotection. Expert Opin Pharmacother 2016; 17:1669-82. [PMID: 27356036 DOI: 10.1080/14656566.2016.1202919] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS), one in a family of age-related neurodegenerative disorders, is marked by predominantly cryptogenic causes, partially elucidated pathophysiology, and elusive treatments. The challenges of ALS are illustrated by two decades of negative drug trials. AREAS COVERED In this article, we lay out the current understanding of disease genesis and physiology in relation to drug development in ALS, stressing important accomplishments and gaps in knowledge. We briefly consider clinical ALS, the ongoing search for biomarkers, and the latest in trial design, highlighting major recent and ongoing clinical trials; and we discuss, in a concluding section on future directions, the prion-protein hypothesis of neurodegeneration and what steps can be taken to end the drought that has characterized drug discovery in ALS. EXPERT OPINION Age-related neurodegenerative disorders are fast becoming major public health problems for the world's aging populations. Several agents offer promise in the near-term, but drug development is hampered by an interrelated cycle of obstacles surrounding etiological, physiological, and biomarkers discovery. It is time for the type of government-funded, public-supported offensive on neurodegenerative disease that has been effective in other fields.
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Affiliation(s)
- H Blasco
- a Inserm U930, Equipe "neurogénétique et neurométabolomique" , Tours , France.,b Université François-Rabelais, Faculté de Médecine , Tours , France.,c Laboratoire de Biochimie et Biologie Moléculaire , CHRU de Tours , Tours , France
| | - F Patin
- a Inserm U930, Equipe "neurogénétique et neurométabolomique" , Tours , France.,b Université François-Rabelais, Faculté de Médecine , Tours , France.,c Laboratoire de Biochimie et Biologie Moléculaire , CHRU de Tours , Tours , France
| | - C R Andres
- a Inserm U930, Equipe "neurogénétique et neurométabolomique" , Tours , France.,b Université François-Rabelais, Faculté de Médecine , Tours , France.,c Laboratoire de Biochimie et Biologie Moléculaire , CHRU de Tours , Tours , France
| | - P Corcia
- a Inserm U930, Equipe "neurogénétique et neurométabolomique" , Tours , France.,b Université François-Rabelais, Faculté de Médecine , Tours , France.,d Centre SLA, Service de Neurologie , CHRU Bretonneau , Tours , France
| | - P H Gordon
- e Northern Navajo Medical Center , Neurology Unit , Shiprock , NM , USA
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Abstract
Amyotrophic lateral sclerosis (ALS) is proving intractable. Difficulties in pre-clinical studies contribute in small measure to this futility, but the chief reason for failure is an inadequate understanding of disease pathogenesis. Many acquired and inherited processes have been advanced as potential causes of ALS but, while they may predispose to disease, it seems increasingly likely that none leads directly to ALS. Rather, two recent overlapping considerations, both involving aberrant protein homeostasis, may provide a better explanation for a common disease phenotype and a common terminal pathogenesis. If so, therapeutic approaches will need to be altered and carefully nuanced, since protein homeostasis is essential and highly conserved. Nonetheless, these considerations provide new optimism in a difficult disease which has hitherto defied treatment.
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Transcriptional analysis reveals distinct subtypes in amyotrophic lateral sclerosis: implications for personalized therapy. Future Med Chem 2016; 7:1335-59. [PMID: 26144267 DOI: 10.4155/fmc.15.60] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is an incurable disease, caused by the loss of the upper and lower motor neurons. The lack of therapeutic progress is mainly due to the insufficient understanding of complexity and heterogeneity underlying the pathogenic mechanisms of ALS. Recently, we analyzed whole-genome expression profiles of motor cortex of sporadic ALS patients, classifying them into two subgroups characterized by differentially expressed genes and pathways. Some of the deregulated genes encode proteins, which are primary targets of drugs currently in preclinical or clinical studies for several clinical conditions, including neurodegenerative diseases. In this review, we discuss in-depth the potential role of these candidate targets in ALS pathogenesis, highlighting their possible relevance for personalized ALS treatments.
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Katz JS, Barohn RJ, Dimachkie MM, Mitsumoto H. The Dilemma of the Clinical Trialist in Amyotrophic Lateral Sclerosis. Neurol Clin 2015; 33:937-47. [DOI: 10.1016/j.ncl.2015.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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DeLoach A, Cozart M, Kiaei A, Kiaei M. A retrospective review of the progress in amyotrophic lateral sclerosis drug discovery over the last decade and a look at the latest strategies. Expert Opin Drug Discov 2015; 10:1099-118. [PMID: 26307158 DOI: 10.1517/17460441.2015.1067197] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Drug discovery for amyotrophic lateral sclerosis (ALS) has experienced a surge in clinical studies and remarkable preclinical milestones utilizing a variety of mutant superoxide dismutase 1 model systems. Of the drugs that were tested and showed positive preclinical effects, none demonstrated therapeutic benefits to ALS patients in clinical settings. AREAS COVERED This review discusses the advances made in drug discovery for ALS and highlights why drug development is proving to be so difficult. It also discusses how a closer look at both preclinical and clinical studies could uncover the reasons why these preclinical successes have yet to result in the availability of an effective drug for clinical use. EXPERT OPINION Valuable lessons from the numerous preclinical and clinical studies supply the biggest advantage in the monumental task of finding a cure for ALS. Obviously, a single design type for ALS clinical trials has not yielded success. The authors suggest a two-pronged approach that may prove essential to achieve clinical efficacy in the identification of novel targets and preclinical testing in multiple models to identify biomarkers that can function in diagnostic, predictive and prognostic roles, and changes to clinical trial design and patient recruitment criteria. The advancement of technology and invention of more powerful tools will further enhance the above. This will give rise to more sophisticated clinical trials with consideration of a range of criteria from: optimum dose, route of delivery, specific biomarkers, pharmacokinetics, pharmacodynamics and toxicology to biomarkers, timing for trial and patients' clinical status.
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Affiliation(s)
- Abigail DeLoach
- a 1 University of Arkansas for Medical Sciences, Department of Neurobiology and Developmental Sciences , Little Rock, AR 72205, USA
| | - Michael Cozart
- b 2 University of Arkansas for Medical Sciences, Department of Pharmacology and Toxicology , Little Rock, AR 72205, USA
| | - Arianna Kiaei
- a 1 University of Arkansas for Medical Sciences, Department of Neurobiology and Developmental Sciences , Little Rock, AR 72205, USA
| | - Mahmoud Kiaei
- a 1 University of Arkansas for Medical Sciences, Department of Neurobiology and Developmental Sciences , Little Rock, AR 72205, USA.,b 2 University of Arkansas for Medical Sciences, Department of Pharmacology and Toxicology , Little Rock, AR 72205, USA.,c 3 University of Arkansas for Medical Sciences, Department of Neurology , 4301 W. Markham St, 846, Little Rock, AR 72205 7199, USA
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Barker-Haliski ML, Friedman D, French JA, White HS. Disease Modification in Epilepsy: From Animal Models to Clinical Applications. Drugs 2015; 75:749-67. [DOI: 10.1007/s40265-015-0395-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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18
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Macchi Z, Wang Y, Moore D, Katz J, Saperstein D, Walk D, Simpson E, Genge A, Bertorini T, Fernandes JA, Swenson A, Elman L, Dimachkie M, Herbelin L, Miller J, Lu J, Wilkins H, Swerdlow RH, Statland J, Barohn R. A multi-center screening trial of rasagiline in patients with amyotrophic lateral sclerosis: Possible mitochondrial biomarker target engagement. Amyotroph Lateral Scler Frontotemporal Degener 2015; 16:345-52. [PMID: 25832828 DOI: 10.3109/21678421.2015.1026826] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Rasagiline, a monoamine oxidase B inhibitor, slowed disease progression in the SOD1 mouse, and in a case series of patients with amyotrophic lateral sclerosis (ALS). Here we determine whether rasagiline is safe and effective in ALS compared to historical placebo controls, and whether it alters mitochondrial biomarkers. We performed a prospective open-label, multicenter screening trial of 36 ALS patients treated with 2 mg oral rasagiline daily for 12 months. Outcomes included the slope of deterioration of the revised ALS Functional Rating Scale (ALSFRS-R), adverse event monitoring, time to treatment failure, and exploratory biomarkers. Participants experienced no serious drug-related adverse events, and the most common adverse event was nausea (11.1%). Rasagiline did not improve the rate of decline in the ALSFRS-R; however, differences in symptom duration compared to historical placebo controls differentially affected ALSFRS-R slope estimates. Rasagiline changed biomarkers over 12 months, such that the mitochondrial membrane potential increased (JC-1 red/green fluorescent ratio 1.92, p = 0.0001) and apoptosis markers decreased (Bcl-2/Bax ratio 0.24, p < 0.0001). In conclusion, engagement of exploratory biomarkers and questions about comparability of baseline characteristics lead us to recommend a further placebo-controlled trial.
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Affiliation(s)
| | - Yunxia Wang
- a University of Kansas Medical Center , Kansas
| | - Dan Moore
- b California Pacific Medical Center , San Francisco , California
| | - Jonathan Katz
- b California Pacific Medical Center , San Francisco , California
| | - David Saperstein
- c Phoenix Neurological Associates , Phoenix , Arizona , Kansas City , Kansas
| | - David Walk
- d University of Minnesota , Minneapolis , Minnesota
| | | | | | | | | | | | - Lauren Elman
- j University of Pennsylvania , Philadelphia , Pennsylvania
| | | | | | | | - Jianghua Lu
- a University of Kansas Medical Center , Kansas
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Nicholson KA, Cudkowicz ME, Berry JD. Clinical Trial Designs in Amyotrophic Lateral Sclerosis: Does One Design Fit All? Neurotherapeutics 2015; 12:376-83. [PMID: 25700798 PMCID: PMC4404442 DOI: 10.1007/s13311-015-0341-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The last 2 decades have seen a surge in the number of amyotrophic lateral sclerosis (ALS) clinical trials with the hope of finding successful treatments. Clinical trialists aim to repurpose existing drugs and test novel compounds to target potential ALS disease pathophysiology. Recent technological advancements have led to the discovery of new causative genetic agents and modes of delivering potential therapy, calling for increasingly sophisticated trial design. The standard ALS clinical trial design may be modified depending on study needs: type of therapy; route of therapy delivery; phase of therapy development; applicable subpopulation; market availability of therapy; and utility of telemedicine. Novel biomarkers of diagnostic, predictive, prognostic, and pharmacodynamic value are undergoing development and validation for use in clinical trials. Design modifications build on the traditional clinical trial design and may be employed in either the learning or confirming trial phase. Novel designs aim to minimize patient risk, study duration, and sample size, while improving efficiency and promoting statistical power to herald an exciting era for clinical research in ALS.
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Affiliation(s)
- Katharine A Nicholson
- Massachusetts General Hospital, Department of Neurology, Neurological Clinical Research Institute, 165 Cambridge Street, Suite 600, Boston, MA, 02114, USA,
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20
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Nelson RM, Roth-Cline M, Prohaska K, Cox E, Borio L, Temple R. Right job, wrong tool: a commentary on designing clinical trials for Ebola virus disease. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:33-6. [PMID: 25856596 DOI: 10.1080/15265161.2015.1010018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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Chiò A, Hammond ER, Mora G, Bonito V, Filippini G. Development and evaluation of a clinical staging system for amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2015; 86:38-44. [PMID: 24336810 DOI: 10.1136/jnnp-2013-306589] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Staging of disease severity is useful for prognosis, decision-making and resource planning. However, no commonly used, validated staging system exists for amyotrophic lateral sclerosis (ALS). Our purpose was to develop an ALS staging system (ALS Milano-Torino Staging) that captures the observed progressive loss of independence and function. METHODS Clinical milestones in ALS progression were defined by loss of independence in four key domains on the ALS Functional Rating Scale (ALSFRS): swallowing, walking/self-care, communicating and breathing. Stages were defined as follows: stage 0, functional involvement but no loss of independence on any domain; stages 1-4, number of domains in which independence was lost; and stage 5, death. Staging criteria were applied to patients enrolled in a Quality of Care in ALS (QOC) study; endpoints included function (ALSFRS), quality of life (QOL; Short Form-36) and health service costs. Between-stage transition probabilities were assessed in the QOC study and in a second clinical study of lithium carbonate in ALS. RESULTS 70/118 (59.3%) participants in the QOC study progressed to higher stages of disease at 12 months compared with their baseline stage. Functional (ALSFRS) and QOL measures were inversely related to disease stage. Health service costs were directly related to increasing disease stages from 0 to 4 (p<0.001). Probabilities for transitioning from a given stage at baseline in both studies were usually greatest for the next highest stage. CONCLUSIONS The proposed ALS Milano-Torino Staging system correlates well with assessments of function, QOL and health service costs. Further studies are warranted to validate this system.
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Affiliation(s)
- Adriano Chiò
- Rita Levi Montalcini Department of Neuroscience, University of Torino, Torino, Italy
| | - Edward R Hammond
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Gabriele Mora
- Department of Neuroscience and Rehabilitation, Fondazione Salvatore Maugeri, IRCCS, Milan, Italy
| | - Virginio Bonito
- Department of Neurology and Neurosurgery, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Graziella Filippini
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Mitsumoto H, Brooks BR, Silani V. Clinical trials in amyotrophic lateral sclerosis: why so many negative trials and how can trials be improved? Lancet Neurol 2014; 13:1127-1138. [DOI: 10.1016/s1474-4422(14)70129-2] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Su XW, Broach JR, Connor JR, Gerhard GS, Simmons Z. Genetic heterogeneity of amyotrophic lateral sclerosis: Implications for clinical practice and research. Muscle Nerve 2014; 49:786-803. [DOI: 10.1002/mus.24198] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2014] [Indexed: 12/26/2022]
Affiliation(s)
- Xiaowei W. Su
- Department of Neurosurgery; The Pennsylvania State University College of Medicine; Hershey Pennsylvania USA
| | - James R. Broach
- Department of Biochemistry and Molecular Biology; The Pennsylvania State University College of Medicine; Hershey Pennsylvania USA
| | - James R. Connor
- Department of Neurosurgery; The Pennsylvania State University College of Medicine; Hershey Pennsylvania USA
| | - Glenn S. Gerhard
- Department of Biochemistry and Molecular Biology; The Pennsylvania State University College of Medicine; Hershey Pennsylvania USA
| | - Zachary Simmons
- Department of Neurology; Penn State Milton S. Hershey Medical Center; 30 Hope Drive (Suite EC037) Hershey Pennsylvania 17033 USA
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Arezzo JC, Seto S, Schaumburg HH. Sensory-motor assessment in clinical research trials. HANDBOOK OF CLINICAL NEUROLOGY 2014; 115:265-78. [PMID: 23931786 DOI: 10.1016/b978-0-444-52902-2.00016-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
The assessment of changes in sensory-motor function in clinical research presents a unique set of difficulties. Clinimetrics is the science of measurement as related to the identification of a clinical disorder, the tracing of the progression of the condition under study, and calculation of its impact. The selection of appropriate measures for clinical studies of sensory-motor function must consider validity, sensitivity, specificity, responsiveness, reliability, and feasibility. Reasonable measures of motor function in clinical research include manual examination of muscle strength, electrophysiology, functional scales, patient-reported outcomes (e.g., quality of life), and for severe conditions such as ALS, survival. The assessment of sensory function includes targeted electrophysiology and QOL, as well as more focused measures such as quantitative sensory testing and the scoring of positive symptoms. Each individual measure and each combination of endpoints has its strengths and limitations.
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Affiliation(s)
- Joseph C Arezzo
- Department of Neuroscience, Albert Einstein College of Medicine, New York, USA; Department of Neurology, Albert Einstein College of Medicine, New York, USA.
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26
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Oliveira GB, Fontes EDA, de Carvalho S, da Silva JB, Fernandes LMP, Oliveira MCSP, Prediger RD, Gomes-Leal W, Lima RR, Maia CSF. Minocycline mitigates motor impairments and cortical neuronal loss induced by focal ischemia in rats chronically exposed to ethanol during adolescence. Brain Res 2014; 1561:23-34. [PMID: 24637259 DOI: 10.1016/j.brainres.2014.03.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 01/29/2014] [Accepted: 03/07/2014] [Indexed: 12/12/2022]
Abstract
Ethanol is an important risk factor for the occurrence of cerebral ischemia contributing to poor prognosis and inefficacy of drug treatments for stroke-related symptoms. Females have a higher lifetime risk for stroke than males. Moreover, female gender has been associated with increased ethanol consumption during adolescence. In the present study, we investigated whether chronic ethanol exposure during adolescence may potentiate the motor impairments and cortical damage induced by focal ischemia in female rats. We also addressed whether these effects can be mitigated by minocycline, which has been shown to be neuroprotective against different insults in the CNS. Female rats were treated with distilled water or ethanol (6.5 g/kg/day, 22.5% w/v) for 55 days by gavage. Focal ischemia was induced by microinjections of endothelin-1 (ET-1) into the motor cortex. Animals of both groups were treated daily with minocycline (25-50 mg/kg, i.p.) or sterile saline (i.p.) for 5 days, and motor function was assessed using open field, inclined plane and rotarod tests. Chronic ethanol exposure exacerbated locomotor activity and motor coordination impairments induced by focal ischemia in rats. Moreover, histological analysis revealed that microinjections of ET-1 induced pyramidal neuron loss and microglial activation in the motor cortex. Minocycline reversed the observed motor impairments, microglial activation and pyramidal neuron loss in the motor cortex of ischemic rats even in those exposed to ethanol. These results suggest that minocycline induces neuroprotection and functional recovery in ischemic female rats intoxicated with ethanol during adolescence. Furthermore, the mechanism underlying this protective effect may be related to the modulation of neuroinflammation.
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Affiliation(s)
- Gedeão Batista Oliveira
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil
| | - Enéas de Andrade Fontes
- Programa de Pós-graduação em Neurociências e Biologia Celular, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil
| | - Sabrina de Carvalho
- Laboratório de Farmacologia da Inflamação e do Comportamento, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil
| | - Josiane Batista da Silva
- Laboratório de Farmacologia da Inflamação e do Comportamento, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil
| | - Luanna Melo Pereira Fernandes
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil; Laboratório de Farmacologia da Inflamação e do Comportamento, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil
| | - Maria Cristina Souza Pereira Oliveira
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil
| | - Rui Daniel Prediger
- Departamento de Farmacologia, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, 88049-900 Florianópolis, SC, Brazil
| | - Walace Gomes-Leal
- Laboratório de Neuroproteção e Neurorregeneração Experimental do Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil
| | - Rafael Rodrigues Lima
- Laboratório de Neuroproteção e Neurorregeneração Experimental do Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil
| | - Cristiane Socorro Ferraz Maia
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil; Programa de Pós-graduação em Neurociências e Biologia Celular, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil; Laboratório de Farmacologia da Inflamação e do Comportamento, Faculdade de Farmácia, Instituto de Ciências da Saúde, Universidade Federal do Pará, 66075-900 Belém, Pará, Brazil.
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Hanumunthadu D, Dehabadi MH, Cordeiro MF. Neuroprotection in glaucoma: current and emerging approaches. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2014.892415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lewis RA, McDermott MP, Herrmann DN, Hoke A, Clawson LL, Siskind C, Feely SME, Miller LJ, Barohn RJ, Smith P, Luebbe E, Wu X, Shy ME. High-dosage ascorbic acid treatment in Charcot-Marie-Tooth disease type 1A: results of a randomized, double-masked, controlled trial. JAMA Neurol 2013; 70:981-7. [PMID: 23797954 DOI: 10.1001/jamaneurol.2013.3178] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE No current medications improve neuropathy in subjects with Charcot-Marie-Tooth disease type 1A (CMT1A). Ascorbic acid (AA) treatment improved the neuropathy of a transgenic mouse model of CMT1A and is a potential therapy. A lower dosage (1.5 g/d) did not cause improvement in humans. It is unknown whether a higher dosage would prove more effective. OBJECTIVE To determine whether 4-g/d AA improves the neuropathy of subjects with CMT1A. DESIGN A futility design to determine whether AA was unable to reduce worsening on the CMT Neuropathy Score (CMTNS) by at least 50% over a 2-year period relative to a natural history control group. SETTING Three referral centers with peripheral nerve clinics (Wayne State University, Johns Hopkins University, and University of Rochester). PARTICIPANTS One hundred seventy-four subjects with CMT1A were assessed for eligibility; 48 did not meet eligibility criteria and 16 declined to participate. The remaining 110 subjects, aged 13 to 70 years, were randomly assigned in a double-masked fashion with 4:1 allocation to oral AA (87 subjects) or matching placebo (23 subjects). Sixty-nine subjects from the treatment group and 16 from the placebo group completed the study. Two subjects from the treatment group and 1 from the placebo group withdrew because of adverse effects. INTERVENTIONS Oral AA (4 g/d) or matching placebo. MAIN OUTCOMES AND MEASURES Change from baseline to year 2 in the CMTNS, a validated composite impairment score for CMT. RESULTS The mean 2-year change in the CMTNS was -0.21 for the AA group and -0.92 for the placebo group, both better than natural history (+1.33). This was well below 50% reduction of CMTNS worsening from natural history, so futility could not be declared (P > .99). CONCLUSIONS AND RELEVANCE Both treated patients and those receiving placebo performed better than natural history. It seems unlikely that our results support undertaking a larger trial of 4-g/d AA treatment in subjects with CMT1A. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00484510.
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Affiliation(s)
- Richard A Lewis
- Department of Neurology, Wayne State University, Detroit, Michigan, USA
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Gordon PH. Amyotrophic Lateral Sclerosis: An update for 2013 Clinical Features, Pathophysiology, Management and Therapeutic Trials. Aging Dis 2013; 4:295-310. [PMID: 24124634 PMCID: PMC3794725 DOI: 10.14336/ad.2013.0400295] [Citation(s) in RCA: 168] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 08/26/2013] [Accepted: 08/27/2013] [Indexed: 01/28/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS), first described by Jean-Martin Charcot in the 1870s, is an age-related disorder that leads to degeneration of motor neurons. The disease begins focally in the central nervous system and then spreads relentlessly. The clinical diagnosis, defined by progressive signs and symptoms of upper and lower motor neuron dysfunction, is confirmed by electromyography. Additional testing excludes other conditions. The disease is heterogeneous, but most patients die of respiratory muscle weakness less than 3 years from symptom-onset. Like other age-related neurodegenerative diseases, ALS has genetic and environmental triggers. Of the five to 10% of cases that are inherited, mutations have been discovered for a high proportion. In addition to genetic factors, age, tobacco use, and athleticism may contribute to sporadic ALS, but important etiologies are unidentified for most patients. Complex pathophysiological processes, including mitochondrial dysfunction, aggregation of misfolded protein, oxidative stress, excitotoxicity, inflammation and apoptosis, involve both motor neurons and surrounding glial cells. There is clinical and pathological overlap with other neurodegenerative diseases, particularly frontotemporal dementia. The mechanisms leading to disease propagation in the brain are a current focus of research. To date, one medication, riluzole, licensed in 1996, has been proved to prolong survival in ALS. Numerous clinical trials have so far been unable to identify another neuroprotective agent. Researchers now aim to slow disease progression by targeting known pathophysiological pathways or genetic defects. Current approaches are directed at muscle proteins such as Nogo, energetic balance, cell replacement, and abnormal gene products resulting from mutations. Until better understanding of the causes and mechanisms underlying progression lead to more robust neuroprotective agents, symptomatic therapies can extend life and improve quality of life. Palliative care programs such as hospice give emotional and physical support to patients and families throughout much of the disease course.
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Affiliation(s)
- Paul H. Gordon
- AP-HP, Hôpital de la Pitié-Salpêtrière, Département des Maladies du Système Nerveux, Paris, France
- Northern Navajo Medical Center, Shiprock, NM 87420, USA
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Li J, Sung M, Rutkove SB. Electrophysiologic biomarkers for assessing disease progression and the effect of riluzole in SOD1 G93A ALS mice. PLoS One 2013; 8:e65976. [PMID: 23762454 PMCID: PMC3675066 DOI: 10.1371/journal.pone.0065976] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 05/04/2013] [Indexed: 12/12/2022] Open
Abstract
Objective To compare electrical impedance myography (EIM) 50 kHz phase to weight, motor score, paw grip endurance (PGE), CMAP amplitude, and MUNE for the identification of disease progression and the effect of riluzole in the SOD1 G93A mouse. Methods Twenty-three animals received 8 mg/kg/day riluzole in the drinking water starting at 6 weeks of age; 22 animals served as controls. Weight, motor score, PGE, CMAP, MUNE, and EIM were performed weekly to evaluate disease progression. Results No difference in clinical disease onset or survival was found between treated and untreated groups. In addition, all methods failed to identify any beneficial effect of riluzole. Thus, data from all animals were combined for additional analyses. Of the 4 parameters, EIM phase showed the earliest change from baseline and the most linear decline throughout the entire measurement period. In addition, EIM phase correlated with PGE, CMAP amplitude, and MUNE (Spearman r = 0.92, 0.90, and 0.72, respectively, p<0.01 for all). The rate of EIM phase decline also correlated with individual animal survival (Spearman r = −0.31, p<0.05). Conclusions At this dose, riluzole is ineffective in slowing progression of ALS. However, EIM phase shows early linear declines, supporting its potential as a useful new biomarker for preclinical drug testing.
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Affiliation(s)
- Jia Li
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Minhee Sung
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Seward B. Rutkove
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
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Gladman M, Cudkowicz M, Zinman L. Enhancing clinical trials in neurodegenerative disorders: lessons from amyotrophic lateral sclerosis. Curr Opin Neurol 2013; 25:735-42. [PMID: 23160423 DOI: 10.1097/wco.0b013e32835a309d] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review article is focused on strategies that may enhance clinical trial efficiency in neurodegenerative disorders, as demonstrated within the research field of amyotrophic lateral sclerosis (ALS). RECENT FINDINGS Unravelling ALS pathophysiology will result in an increased number of candidate therapeutics. Recent ALS clinical trials have employed novel study designs that expedite the drug development process and limit sample size, including futility, lead-in, selection, adaptive and sequential designs. The search for sensitive and specific biomarkers in ALS continues to develop, and they are essential in accelerating the drug discovery process. Several candidate cerebrospinal fluid (CSF), neuroimaging and electrophysiological biomarkers have been recently described in ALS, and some have been successfully employed as secondary outcome measures in clinical trials. The advent of web-based technologies has provided a complementary platform to expedite clinical trials, through electronic data capture, teleconferencing and online registries. In addition, the formation of ALS consortia has enhanced collaborative multicentre studies. SUMMARY ALS research studies have employed novel strategies to accelerate the efficiency and pace of drug discovery. The importance of adapting to novel measures that enhance study efficiency is not unique to ALS and can be applied to other neurodegenerative diseases in search of effective treatments.
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Affiliation(s)
- Matthew Gladman
- Department of Medicine, University of Toronto Medical School, Toronto, Ontario, Canada
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A pilot open-label trial of minocycline in patients with autism and regressive features. J Neurodev Disord 2013; 5:9. [PMID: 23566357 PMCID: PMC3663771 DOI: 10.1186/1866-1955-5-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 03/20/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Minocycline is a tetracycline derivative that readily crosses the blood brain barrier and appears to have beneficial effects on neuroinflammation, microglial activation and neuroprotection in a variety of neurological disorders. Both microglial activation and neuroinflammation have been reported to be associated with autism. The study was designed to evaluate the effects of minocycline treatment on markers of neuroinflammation and autism symptomatology in children with autism and a history of developmental regression. METHODS Eleven children were enrolled in an open-label trial of six months of minocycline (1.4 mg/kg). Ten children completed the trial. Behavioral measures were collected and cerebrospinal fluid (CSF), serum and plasma were obtained before and at the end of minocycline treatment and were analyzed for markers of neuroinflammation. RESULTS Clinical improvements were negligible. The laboratory assays demonstrated significant changes in the expression profile of the truncated form of brain derived neurotrophic factor (BDNF) (P = 0.042) and hepatic growth factor (HGF) (P = 0.028) in CSF. In serum, the ratio of the truncated BDNF form and α-2 macroglobulin (α-2 M), was also significantly lower (P = 0.028) while the mature BDNF/α-2 M ratio revealed no difference following treatment. Only the chemokine CXCL8 (IL-8) was significantly different (P = 0.047) in serum while no significant changes were observed in CSF or serum in chemokines such as CCL2 (MCP-1) or cytokines such as TNF-α, CD40L, IL-6, IFN-γ and IL-1β when pre- and post-treatment levels of these proteins were compared. No significant pre- and post-treatment changes were seen in the profiles of plasma metalloproteinases, putative targets of the effects of minocycline. CONCLUSIONS Changes in the pre- and post-treatment profiles of BDNF in CSF and blood, HGF in CSF and CXCL8 (IL-8) in serum, suggest that minocycline may have effects in the CNS by modulating the production of neurotrophic growth factors. However, in this small group of children, no clinical improvements were observed during or after the six months of minocycline administration. TRIAL REGISTRATION NCT00409747.
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Cummings J, Gould H, Zhong K. Advances in designs for Alzheimer's disease clinical trials. AMERICAN JOURNAL OF NEURODEGENERATIVE DISEASE 2012; 1:205-216. [PMID: 23383393 PMCID: PMC3560467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 10/29/2012] [Indexed: 06/01/2023]
Abstract
There is an urgent need to identify new treatments for the rapidly growing population of people with Alzheimer's disease (AD). Innovations in clinical trial designs many help to reduce development time, provide more definitive answers regarding drug efficacy, and facilitate prioritizing compounds to be advanced to Phase III clinical trials. Standard designs compare drug and placebo changes from baseline on a rating scale. Baysian adaptive clinical trials allow the use of data collected in the trial to modify doses, sample size, trial duration, and entry criteria in an ongoing way as the data are collected. Disease-modification is supported by findings on staggered start and delayed withdrawal designs. Futility designs can use historical controls and may shorten trial duration. Combination therapy designs may allow investigation of additive or synergistic treatment effects. Novel trial selection criteria allow investigation of treatment effects in asymptomatic or minimally symptomatic, prodromal AD populations. The Clinical Dementia Rating-Sum of Boxes (CDR-SOB) can be considered as a single trial outcome in early disease populations. Alternate forms of the Alzheimer's Disease Assessment Scale-Cognitive Portion (ADAS-cog), computerized measures, and pharmacoeconomic scales provide new and relevant information on drug effects. Comparative dose strategies are used in trials of symptomatic agents, and novel methods including withdrawal designs, symptom emergence analyses, and sequential designs are being utilized to assess the efficacy of putative psychotropic agents. The choice of trial design is driven by the question to be answered by the clinical trial; an increasing number of design approaches are available and may be useful in accelerating and refining AD drug development.
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Affiliation(s)
- Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health Las Vegas, Nevada; Cleveland, Ohio; Weston, Florida
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Corcia P, Gordon PH. Amyotrophic lateral sclerosis and the clinical potential of dexpramipexole. Ther Clin Risk Manag 2012; 8:359-66. [PMID: 22956874 PMCID: PMC3431958 DOI: 10.2147/tcrm.s21981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder that leads to progressive weakness from loss of motor neurons and death on average in less than 3 years after symptom onset. No clear causes have been found and just one medication, riluzole, extends survival. Researchers have identified some of the cellular processes that occur after disease onset, including mitochondrial dysfunction, protein aggregation, oxidative stress, excitotoxicity, inflammation, and apoptosis. Mitochondrial disease may be a primary event in neurodegeneration or occur secondary to other cellular processes, and may itself contribute to oxidative stress, excitotoxicity, and apoptosis. Clinical trials currently aim to slow disease progression by testing drugs that impact one or more of these pathways. While every agent tested in the 18 years after the approval of riluzole has been ineffective, basic and clinical research methods in ALS have become dramatically more sophisticated. Dexpramipexole (RPPX), the R(+) enantiomer of pramiprexole, which is approved for symptomatic treatment of Parkinson disease, carries perhaps the currently largest body of pre-and early clinical data that support testing in ALS. The neuroprotective properties of RPPX in various models of neurodegeneration, including the ALS murine model, may be produced through protective actions on mitochondria. Early phase trials in human ALS suggest that the drug can be taken safely by patients in doses that provide neuroprotection in preclinical models. A Phase III trial to test the efficacy of RPPX in ALS is underway.
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Affiliation(s)
- Philippe Corcia
- Centre SLA, CHRU de Tours, Tours, France; UMR INSERM U930, Université François Rabelais de Tours (PC), Tours, France
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Sumracki NM, Hutchinson MR, Gentgall M, Briggs N, Williams DB, Rolan P. The effects of pregabalin and the glial attenuator minocycline on the response to intradermal capsaicin in patients with unilateral sciatica. PLoS One 2012; 7:e38525. [PMID: 22685578 PMCID: PMC3369912 DOI: 10.1371/journal.pone.0038525] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 05/05/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with unilateral sciatica have heightened responses to intradermal capsaicin compared to pain-free volunteers. No studies have investigated whether this pain model can screen for novel anti-neuropathic agents in patients with pre-existing neuropathic pain syndromes. AIM This study compared the effects of pregabalin (300 mg) and the tetracycline antibiotic and glial attenuator minocycline (400 mg) on capsaicin-induced spontaneous pain, flare, allodynia and hyperalgesia in patients with unilateral sciatica on both their affected and unaffected leg. METHODS/RESULTS Eighteen patients with unilateral sciatica completed this randomised, double-blind, placebo-controlled, three-way cross-over study. Participants received a 10 µg dose of capsaicin into the middle section of their calf on both their affected and unaffected leg, separated by an interval of 75 min. Capsaicin-induced spontaneous pain, flare, allodynia and hyperalgesia were recorded pre-injection and at 5, 20, 40, 60 and 90 min post-injection. Minocycline tended to reduce pre-capsaicin injection values of hyperalgesia in the affected leg by 28% (95% CI 0% to 56%). The area under the effect time curves for capsaicin-induced spontaneous pain, flare, allodynia and hyperalgesia were not affected by either treatment compared to placebo. Significant limb differences were observed for flare (AUC) (-38% in affected leg, 95% CI for difference -19% to -52%). Both hand dominance and sex were significant covariates of response to capsaicin. CONCLUSIONS It cannot be concluded that minocycline is unsuitable for further evaluation as an anti-neuropathic pain drug as pregabalin, our positive control, failed to reduce capsaicin-induced neuropathic pain. However, the anti-hyperalgesic effect of minocycline observed pre-capsaicin injection is promising pilot information to support ongoing research into glial-mediated treatments for neuropathic pain. The differences in flare response between limbs may represent a useful biomarker to further investigate neuropathic pain. Inclusion of a positive control is imperative for the assessment of novel therapies for neuropathic pain.
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Affiliation(s)
- Nicole M Sumracki
- Discipline of Pharmacology, School of Medical Sciences, University of Adelaide, Adelaide, Australia.
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Shin JH, Lee YA, Lee JK, Lee YB, Cho W, Im DS, Lee JH, Yun BS, Springer JE, Gwag BJ. Concurrent blockade of free radical and microsomal prostaglandin E synthase-1-mediated PGE2 production improves safety and efficacy in a mouse model of amyotrophic lateral sclerosis. J Neurochem 2012; 122:952-61. [PMID: 22537108 DOI: 10.1111/j.1471-4159.2012.07771.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While free radicals and inflammation constitute major routes of neuronal injury occurring in amyotrophic lateral sclerosis (ALS), neither antioxidants nor non-steroidal anti-inflammatory drugs have shown significant efficacy in human clinical trials. We examined the possibility that concurrent blockade of free radicals and prostaglandin E(2) (PGE(2))-mediated inflammation might constitute a safe and effective therapeutic approach to ALS. We have developed 2-hydroxy-5-[2-(4-trifluoromethylphenyl)-ethylaminobenzoic acid] (AAD-2004) as a derivative of aspirin. AAD-2004 completely removed free radicals at 50 nM as a potent spin-trapping molecule and inhibited microsomal PGE(2) synthase-1 (mPGES-1) activity in response to both lipopolysaccharide-treated BV2 cell with IC(50) of 230 nM and recombinant human mPGES-1 protein with IC(50) of 249 nM in vitro. In superoxide dismutase 1(G93A) transgenic mouse model of ALS, AAD-2004 blocked free radical production, PGE(2) formation, and microglial activation in the spinal cords. As a consequence, AAD-2004 reduced autophagosome formation, axonopathy, and motor neuron degeneration, improving motor function and increasing life span. In these assays, AAD-2004 was superior to riluzole or ibuprofen. Gastric bleeding was not induced by AAD-2004 even at a dose 400-fold higher than that required to obtain maximal therapeutic efficacy in superoxide dismutase 1(G93A). Targeting both mPGES-1-mediated PGE(2) and free radicals may be a promising approach to reduce neurodegeneration in ALS and possibly other neurodegenerative diseases.
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Affiliation(s)
- Jin Hee Shin
- Department of Neuroscience, Ajou University School of Medicine, Suwon, South Korea GNT Pharma, Yongin, South Korea
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Baldinger R, Katzberg HD, Weber M. Treatment for cramps in amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2012:CD004157. [PMID: 22513921 DOI: 10.1002/14651858.cd004157.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cramps are painful, involuntary muscle contractions. They commonly affect people with amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) at all stages of the disease. To date, the treatment of muscle cramps in ALS has been largely empirical without any evidence from randomised controlled trials. OBJECTIVES To systematically assess the effect of interventions on muscle cramps as a primary or secondary endpoint or adverse event in people with ALS/MND. SEARCH METHODS We searched the Cochrane Neuromuscular Disease Group Specialized Register (14 February 2011), the Cochrane Central Register of Controlled Trials (Issue 1, 2011 in The Cochrane Library), MEDLINE (January 1966 to January 2011) and EMBASE (January 1980 to January 2011) and reference lists of articles searched using the terms motor neuron disease, motor neurone disease, motoneuron disease or amyotrophic lateral sclerosis. We contacted authors of trials for further information. SELECTION CRITERIA We included all randomised and quasi-randomised trials of oral medications in people with ALS which assessed cramps as a primary or secondary outcome measure or as an adverse event. We also included trials using subcutaneous or intravenous medications or physical therapy. DATA COLLECTION AND ANALYSIS All authors applied the selection criteria and assessed study quality independently, and all authors performed independent data extraction. MAIN RESULTS Twenty studies including 4789 participants were identified. Only one trial, of tetrahydrocannabinol (THC), assessed cramps as the primary endpoint. Thirteen studies assessed cramps as a secondary endpoint. The medications comprised vitamin E, baclofen, riluzole, L-threonine, xaliproden, indinavir, and memantine. Six studies assessed cramps as an adverse event. The medications comprised creatine, gabapentin, dextromethorphan, quinidine, and lithium. In all 20 studies no favourable effect for the treatment of cramps in ALS/MND could be demonstrated, but many studies were underpowered to draw a definite conclusion. A meta-analysis of two small studies showed a statistically nonsignificant result for the amino acid L-threonine for the treatment of cramps in ALS/MND. No study was identified using physical therapy as a therapeutic intervention for cramps. AUTHORS' CONCLUSIONS There is no evidence to support the use of any intervention for muscle cramps in ALS/MND. More and larger randomised controlled trials evaluating treatments for muscle cramps in ALS/MND are needed.
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Affiliation(s)
- Reto Baldinger
- Muskelzentrum/ALS Clinic, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Moore DH, Katz JS, Miller RG. A review of clinical trial designs in amyotrophic lateral sclerosis. Neurodegener Dis Manag 2011. [DOI: 10.2217/nmt.11.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
SUMMARY Amyotrophic lateral sclerosis is a serious disease characterized by a rapid decline in the ability to carry out daily activities, which leads to death within 2–5 years of diagnosis. Numerous agents for slowing disease progression have been tested but only one (riluzole) has proven to be moderately successful. Here we review clinical trial designs with a focus on novel Phase II designs developed since 2005, that attempt to speed up the process of testing new agents. The review is organized by four features that are critical in defining a clinical trial: the comparison group, the end point, the method of analysis and the type of trial. We note continuing trends over the past 5 years toward more efficient designs with shorter duration trials, increased interest in biomarkers and use of well-characterized historical controls.
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Berry JD, Cudkowicz ME. New considerations in the design of clinical trials for amyotrophic lateral sclerosis. CLINICAL INVESTIGATION 2011; 1:1375-1389. [PMID: 22545191 PMCID: PMC3335743 DOI: 10.4155/cli.11.127] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Amyotrophic lateral sclerosis is a devastating neurodegenerative disease caused by loss of motor neurons. Its pathophysiology remains unknown, but progress has been made in understanding its genetic and biochemical basis. Clinical trialists are working to translate basic science successes into human trials with more efficiency, in the hope of finding successful treatments. In the future, new preclinical models, including patient-derived stem cells may augment transgenic animal models as preclinical tools. Biomarker discovery projects aim to identify markers of disease onset and progression for use in clinical trials. New trial designs are reducing study time, improving efficiency and helping to keep pace with the increasing rate of basic and translational discoveries. Ongoing trials with novel designs are paving the way for amyotrophic lateral sclerosis clinical research.
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Affiliation(s)
- James D Berry
- Massachusetts General Hospital, Department of Neurology, Neurology Clinical Trials Unit, 149 Thirteenth Street, Suite 2274, Charlestown, MA 02129, USA
| | - Merit E Cudkowicz
- Massachusetts General Hospital, Department of Neurology, Neurology Clinical Trials Unit, 149 Thirteenth Street, Suite 2274, Charlestown, MA 02129, USA
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Abstract
Since the approval of riluzole for the treatment of amyotrophic lateral sclerosis (ALS) 17 years ago, more than 30 large clinical trials have been conducted, but none has proved successful. The failure to translate positive preclinical results into the clinical setting raises questions about the validity of the rodent model that is used to study ALS, and about the quality of both preclinical and clinical studies. However, the greatest challenge is the disease itself as, with rare exceptions, the causes are unknown. In this Perspectives article, we highlight key issues related to the pathophysiology, preclinical studies and clinical trials that should be addressed in the future. These areas include the relationships between different disease mechanisms, the challenges presented by the heterogeneity of the disease, and the need for early intervention, optimal dose selection and effective biomarkers.
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Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disease that results in increasing disability and that is uniformly fatal. Since its approval in the 1990s, riluzole remains the sole treatment for ALS offering modest survival benefit. While significant advances have been made in the symptomatic management of the disease, more effective drug therapy targeting disease progression is sorely needed. AREAS COVERED Advances in the understanding of pathogenic mechanisms involved in disease development and progression have provided multiple avenues for developing effective treatment strategies. This review highlights recent discoveries relating to these diverse mechanisms and their implications for the development of drug therapy. Previous human clinical trials that have targeted these pathways are mentioned and ongoing drug trials are discussed. EXPERT OPINION The search for effective drug therapy faces important challenges in the areas of basic science and animal research, translation of these results into human clinical trials, inherent bias in human studies and issues related to delays in clinical diagnosis. How these issues may be addressed and why ALS research constitutes fertile grounds for drug development not only for this devastating disease, but also for other more prevalent neurodegenerative diseases, is discussed in this review.
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Affiliation(s)
- Ali Aamer Habib
- The Neurological Institute of Columbia University, Eleanor and Lou Gehrig MDA/ALS Center, NY 10032, USA.
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Klopstock T, Elstner M, Bender A. Creatine in mouse models of neurodegeneration and aging. Amino Acids 2011; 40:1297-303. [PMID: 21390530 DOI: 10.1007/s00726-011-0850-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Accepted: 11/18/2010] [Indexed: 12/12/2022]
Abstract
The supplementation of creatine has shown a marked neuroprotective effect in mouse models of neurodegenerative diseases (Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis). This has been assigned to the known bioenergetic, anti-apoptotic, anti-excitotoxic and anti-oxidant properties of creatine. As aging and neurodegeneration share pathophysiological pathways, we investigated the effect of oral creatine supplementation on aging in 162 aged wild-type C57Bl/6J mice. The median healthy life span of creatine-fed mice was 9% higher than in their control littermates, and they performed significantly better in neurobehavioral tests. In brains of creatine-treated mice, there was a trend toward a reduction of reactive oxygen species and significantly lower accumulation of the "aging pigment" lipofuscin. Expression profiling showed an upregulation of genes implicated in neuronal growth, neuroprotection, and learning. These data showed that creatine improves health and longevity in mice. Creatine may, therefore, be a promising food supplement to promote healthy human aging. However, the strong neuroprotective effects in animal studies of creatine have not been reproduced in human clinical trials (that have been conducted in Parkinson's disease, Huntington's disease, and amyotrophic lateral sclerosis). The reasons for this translational gap are discussed. One obvious cause seems to be that all previous human studies may have been underpowered. Large phase III trials over long time periods are currently being conducted for Parkinson's disease and Huntington's disease, and will possibly solve this issue.
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Affiliation(s)
- T Klopstock
- Department of Neurology, Friedrich-Baur-Institute, University of Munich, Ziemssenstrasse 1, Munich, Germany.
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Cheah BC, Vucic S, Krishnan AV, Boland RA, Kiernan MC. Neurophysiological index as a biomarker for ALS progression: Validity of mixed effects models. ACTA ACUST UNITED AC 2011; 12:33-8. [DOI: 10.3109/17482968.2010.531742] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Utari A, Chonchaiya W, Rivera SM, Schneider A, Hagerman RJ, Faradz SMH, Ethell IM, Nguyen DV. Side effects of minocycline treatment in patients with fragile X syndrome and exploration of outcome measures. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2010; 115:433-43. [PMID: 20687826 PMCID: PMC4031088 DOI: 10.1352/1944-7558-115.5.433] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Minocycline can rescue the dendritic spine and synaptic structural abnormalities in the fragile X knock-out mouse. This is a review and preliminary survey to document side effects and potential outcome measures for minocycline use in the treatment of individuals with fragile X syndrome. We surveyed 50 patients with fragile X syndrome who received minocycline for at least 2 weeks and found that the most common reported side effect is gastrointestinal difficulty, including loss of appetite. The families reported an improvement in language and behavioral areas. Outcome measures in the design of future randomized clinical trials should include both behavioral and language measures. As with any other treatments, we emphasize that randomized clinical trials are needed to determine the efficacy of minocycline in fragile X syndrome.
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Affiliation(s)
- Agustini Utari
- M.I.N.D. Institute, University of California at Davis Medical Center, USA
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Henriques A, Pitzer C, Schneider A. Neurotrophic growth factors for the treatment of amyotrophic lateral sclerosis: where do we stand? Front Neurosci 2010; 4:32. [PMID: 20592948 PMCID: PMC2902233 DOI: 10.3389/fnins.2010.00032] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Accepted: 05/07/2010] [Indexed: 12/12/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease that results in progressive loss of motoneurons, motor weakness and death within 3–5 years after disease onset. Therapeutic options remain limited despite substantial number of approaches that have been tested clinically. Many neurotrophic growth factors are known to promote the survival of neurons and foster regeneration in the central nervous system. Various neurotrophic factors have been investigated pre-clinically and clinically for the treatment of ALS. Although pre-clinical data appeared promising, no neurotrophic factors succeeded yet in a clinical phase III trial. In this review we discuss the rationale behind those factors, possible reasons for clinical failures, and argue for a renewal of hope in this powerful class of drugs for the treatment of ALS.
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van Dijk JP, Schelhaas HJ, Van Schaik IN, Janssen HMHA, Stegeman DF, Zwarts MJ. Monitoring disease progression using high-density motor unit number estimation in amyotrophic lateral sclerosis. Muscle Nerve 2010; 42:239-44. [PMID: 20544934 DOI: 10.1002/mus.21680] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Johannes P van Dijk
- Department of Neurology, Clinical Neurophysiology-920, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Vinukonda G, Csiszar A, Hu F, Dummula K, Pandey NK, Zia MT, Ferreri NR, Ungvari Z, LaGamma EF, Ballabh P. Neuroprotection in a rabbit model of intraventricular haemorrhage by cyclooxygenase-2, prostanoid receptor-1 or tumour necrosis factor-alpha inhibition. ACTA ACUST UNITED AC 2010; 133:2264-80. [PMID: 20488889 DOI: 10.1093/brain/awq107] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intraventricular haemorrhage is a major complication of prematurity that results in neurological dysfunctions, including cerebral palsy and cognitive deficits. No therapeutic options are currently available to limit the catastrophic brain damage initiated by the development of intraventricular haemorrhage. As intraventricular haemorrhage leads to an inflammatory response, we asked whether cyclooxygenase-2, its derivative prostaglandin E2, prostanoid receptors and pro-inflammatory cytokines were elevated in intraventricular haemorrhage; whether their suppression would confer neuroprotection; and determined how cyclooxygenase-2 and cytokines were mechanistically-linked. To this end, we used our rabbit model of intraventricular haemorrhage where premature pups, delivered by Caesarian section, were treated with intraperitoneal glycerol at 2 h of age to induce haemorrhage. Intraventricular haemorrhage was diagnosed by head ultrasound at 6 h of age. The pups with intraventricular haemorrhage were treated with inhibitors of cyclooxygenase-2, prostanoid receptor-1 or tumour necrosis factor-α; and cell-infiltration, cell-death and gliosis were compared between treated-pups and vehicle-treated controls during the first 3 days of life. Neurobehavioural performance, myelination and gliosis were assessed in pups treated with cyclooxygenase-2 inhibitor compared to controls at Day 14. We found that both protein and messenger RNA expression of cyclooxygenase-2, prostaglandin E2, prostanoid receptor-1, tumour necrosis factor-α and interleukin-1β were consistently higher in the forebrain of pups with intraventricular haemorrhage relative to pups without intraventricular haemorrhage. However, cyclooxygenase-1 and prostanoid receptor 2-4 levels were comparable in pups with and without intraventricular haemorrhage. Cyclooxygenase-2, prostanoid receptor-1 or tumour necrosis factor-α inhibition reduced inflammatory cell infiltration, apoptosis, neuronal degeneration and gliosis around the ventricles of pups with intraventricular haemorrhage. Importantly, cyclooxygenase-2 inhibition alleviated neurological impairment, improved myelination and reduced gliosis at 2 weeks of age. Cyclooxygenase-2 or prostanoid receptor-1 inhibition reduced tumour necrosis factor-α level, but not interleukin-1β. Conversely, tumour necrosis factor-α antagonism did not affect cyclooxygenase-2 expression. Hence, prostanoid receptor-1 and tumour necrosis factor-α are downstream to cyclooxygenase-2 in the inflammatory cascade induced by intraventricular haemorrhage, and cyclooxygenase-2-inhibition or suppression of downstream molecules--prostanoid receptor-1 or tumour necrosis factor-α--might be a viable neuroprotective strategy for minimizing brain damage in premature infants with intraventricular haemorrhage.
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Affiliation(s)
- Govindaiah Vinukonda
- Department of Paediatrics, New York Medical College-Westchester Medical Centre, Valhalla, NY 10595, USA
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Glass CK, Saijo K, Winner B, Marchetto MC, Gage FH. Mechanisms underlying inflammation in neurodegeneration. Cell 2010; 140:918-34. [PMID: 20303880 DOI: 10.1016/j.cell.2010.02.016] [Citation(s) in RCA: 2505] [Impact Index Per Article: 178.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 01/25/2010] [Accepted: 02/05/2010] [Indexed: 02/08/2023]
Abstract
Inflammation is associated with many neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, and multiple sclerosis. In this Review, we discuss inducers, sensors, transducers, and effectors of neuroinflammation that contribute to neuronal dysfunction and death. Although inducers of inflammation may be generated in a disease-specific manner, there is evidence for a remarkable convergence in the mechanisms responsible for the sensing, transduction, and amplification of inflammatory processes that result in the production of neurotoxic mediators. A major unanswered question is whether pharmacological inhibition of inflammation pathways will be able to safely reverse or slow the course of disease.
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Affiliation(s)
- Christopher K Glass
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, 92093, USA.
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