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Adiao KJ, Espiritu A, Bagnas MA. Efficacy and safety of mexiletine in amyotrophic lateral sclerosis: a systematic review of randomized controlled trials. Neurodegener Dis Manag 2020; 10:397-407. [PMID: 32867586 DOI: 10.2217/nmt-2020-0026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Mexiletine is a potential drug in amyotrophic lateral sclerosis (ALS) that has been tested in clinical trials. The objective of this study was to determine the efficacy and safety of mexiletine in ALS via systematic review of existing evidences. Materials & methods: Relevant records were searched using major healthcare electronic databases. Data on functional disability, impairment, survival, muscle cramp frequency and severity, and adverse events were obtained. Results & conclusion: Three relevant randomized controlled trials with 141 patients were included in this review. Mexiletine has no effect on the functional disability, impairment and survival in ALS. However, significant improvement in reducing muscle cramp severity and frequency was shown. The most common adverse effect associated with mexiletine intake among ALS patients are nausea (n = 11, 7.8%) and tremors (n = 5, 3.6%).
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Affiliation(s)
- Karen Joy Adiao
- Division of Adult Neurology, Department of Neurosciences, College of Medicine & Philippine General Hospital, University of the Philippines Manila, Manila 1300, Philippines
| | - Adrian Espiritu
- Division of Adult Neurology, Department of Neurosciences, College of Medicine & Philippine General Hospital, University of the Philippines Manila, Manila 1300, Philippines.,Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila 1300, Philippines
| | - Marjorie Anne Bagnas
- Electromyography-Nerve Conduction Velocity (EMG-NCV) Unit, Division of Adult Neurology, Department of Neurosciences, Philippine General Hospital, University of the Philippines Manila, Manila 1300, Philippines
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Oskarsson B, Moore D, Mozaffar T, Ravits J, Wiedau-Pazos M, Parziale N, Joyce NC, Mandeville R, Goyal N, Cudkowicz ME, Weiss M, Miller RG, McDonald CM. Mexiletine for muscle cramps in amyotrophic lateral sclerosis: A randomized, double-blind crossover trial. Muscle Nerve 2018; 58:10.1002/mus.26117. [PMID: 29510461 PMCID: PMC6126993 DOI: 10.1002/mus.26117] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION More than 90% of amyotrophic lateral sclerosis (ALS) patients have muscle cramps, but evidence-based treatments have not been available. METHODS A multicenter, double-blind, placebo-controlled crossover trial of mexiletine 150 mg twice daily was conducted in ALS patients requesting treatment of symptomatic muscle cramps. RESULTS Muscle cramp frequency was reduced in 18 of 20 patients; 13 reductions were attributed to treatment (P < 0.05). The average reduction, based on t tests, was 1.8 cramps per day (a reduction from 5.3 with placebo to 3.5 with mexiletine). The estimated reduction of cramp severity was 15 units on a 100-unit scale (P = 0.01) from a baseline average of 46. No effect on fasciculations was noted. One patient discontinued the study because of dizziness, and another patient discontinued the study to start open-label mexiletine therapy. No serious adverse event occurred. DISCUSSION Mexiletine is a well tolerated and effective medication for controlling the symptom of muscle cramps in ALS. Muscle Nerve, 2018.
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Affiliation(s)
- Björn Oskarsson
- University of California, Davis, Sacramento, California, USA
| | - Dan Moore
- Pacific Medical Center, San Francisco, California, USA
| | | | - John Ravits
- University of California, San Diego, San Diego, California, USA
| | | | | | - Nanette C Joyce
- University of California, Davis, Sacramento, California, USA
| | - Ross Mandeville
- University of California, San Diego, San Diego, California, USA
| | - Namita Goyal
- University of California, Irvine, Irvine, California, USA
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3
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Hwang JT, Kim Y, Bachman DR, Shields MN, Berglund LJ, Fitzsimmons AT, Fitzsimmons JS, O'Driscoll SW. Axial load transmission through the elbow during forearm rotation. J Shoulder Elbow Surg 2018; 27:530-537. [PMID: 29290603 DOI: 10.1016/j.jse.2017.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 10/09/2017] [Accepted: 10/18/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Forearm rotation is closely associated with the axiorotational force transmission through the elbow joint. A technique has been developed to study the transmission of force across the radiocapitellar and ulnotrochlear joints during forearm rotation. METHODS Ten human cadaveric upper limbs were prepared on a custom-designed apparatus that permits the application of extrinsic axial loads across an intact cadaveric elbow joint. A force-sensitive transducer was inserted into the elbow joint of each cadaver. A 160 N axial force was applied to the specimen during cyclic forearm rotation while the force, contact pressure, and contact area through the elbow joint were measured. RESULTS The mean force across the radiocapitellar joint showed no significant difference between pronation and supination (P = .3547). The radiocapitellar joint showed significantly higher contact area (P = .0001) and lower contact pressure (P = .0001) in pronation than in supination. The mean values for contact pressure, area, and force across the ulnotrochlear joint were not significantly different between supination and pronation. CONCLUSION The contact pressure and contact area of the radiocapitellar joint in the cadaveric model changed according to forearm rotation while the force remained constant. The mean contact pressure of the radiocapitellar joint in pronation was significantly lower than that in supination because the force across it did not change significantly and its contact area decreased significantly. These findings may suggest that the pronated elbow can play an important role in protecting the radiocapitellar joint in high-impact activities like delivering punch in martial arts or falling on an outstretched arm.
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Affiliation(s)
- Jung-Taek Hwang
- Department of Orthopedics, Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA; Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon, Republic of Korea
| | - Youngbok Kim
- Department of Orthopedics, Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Daniel R Bachman
- Department of Orthopedics, Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Maegan N Shields
- Department of Orthopedics, Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Lawrence J Berglund
- Department of Orthopedics, Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | | | - James S Fitzsimmons
- Department of Orthopedics, Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Shawn W O'Driscoll
- Department of Orthopedics, Biomechanics Laboratory, Mayo Clinic, Rochester, MN, USA.
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Shafiq F, Mitsikostas DD, Zis P. Nocebo in motor neuron disease: systematic review and meta-analysis of placebo-controlled clinical trials. Amyotroph Lateral Scler Frontotemporal Degener 2017; 18:576-582. [DOI: 10.1080/21678421.2017.1335325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Faiza Shafiq
- Department of Neurology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK,
| | | | - Panagiotis Zis
- Department of Neurology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK,
- Academic Directorate of Neurosciences, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
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Diana A, Pillai R, Bongioanni P, O'Keeffe AG, Miller RG, Moore DH. Gamma aminobutyric acid (GABA) modulators for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2017; 1:CD006049. [PMID: 28067943 PMCID: PMC6953368 DOI: 10.1002/14651858.cd006049.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Imbalance of gamma aminobutyric acid (GABA) and related modulators has been implicated as an important factor in the pathogenesis of amyotrophic lateral sclerosis (ALS), which is also known as motor neuron disease (MND). In this context, the role and mechanism of action of gabapentin and baclofen have been extensively investigated, although with conflicting results. This is the first systematic review to assess clinical trials of GABA modulators for the treatment of ALS. OBJECTIVES To examine the efficacy of gabapentin, baclofen, or other GABA modulators in delaying the progression of ALS, and to evaluate adverse effects of these interventions SEARCH METHODS On 16 August 2016, we searched the Cochrane Neuromuscular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, AMED, and LILACS. In addition, we checked the bibliographies of the trials found in order to identify any other trials, and contacted trial authors to identify relevant unpublished results or additional clinical trials. On 30 August 2016, we searched two clinical trials registries. SELECTION CRITERIA Types of studies: double-blind randomized controlled trials (RCTs) or quasi-RCTsTypes of participants: adults with a diagnosis of probable or definite ALSTypes of interventions: gabapentin, baclofen, or other GABA modulators compared with placebo, no treatment, or each otherPrimary outcome: survival at one year from study enrollmentSecondary outcomes: individual rate of decline of maximum voluntary isometric contraction (MVIC), expressed as arm megascore; rate of decline of per cent predicted forced vital capacity (FVC); rate of decline of ALS Functional Rating Scale (ALSFRS); health-related quality of life; survival evaluated by pooling hazards; and adverse events DATA COLLECTION AND ANALYSIS: At least two review authors independently checked titles and abstracts identified by the searches. The review authors obtained and independently analyzed original individual participant data from each included study; additional review authors and the Cochrane Neuromuscular Managing Editor checked the outcome data. Two authors independently assessed the risk of bias in included studies. Data collection and analysis At least two review authors independently checked titles and abstracts identified by the searches. The review authors obtained and independently analyzed original individual participant data from each included study; additional review authors and the Cochrane Neuromuscular Managing Editor checked the outcome data. Two authors independently assessed the risk of bias in included studies. MAIN RESULTS We identified two double-blind RCTs of gabapentin treatment in ALS for inclusion in this review. We found no eligible RCTs of baclofen or other GABA modulators. The selected studies were phase II and phase III trials, which lasted six and nine months, respectively. They were highly comparable because both were comparisons of oral gabapentin and placebo, performed by the same investigators. The trials enrolled 355 participants with ALS: 80 in the gabapentin group and 72 in the placebo group in the first (phase II) trial and 101 in the gabapentin group and 102 in the placebo group in the second (phase III) trial. Neither trial was long enough to report survival at one year, which was our primary outcome. We found little or no difference in estimated one-year survival between the treated group and the placebo group (78% versus 77%, P = 0.63 by log-rank test; high-quality evidence). We also found little or no difference in the rate of decline of MVIC expressed as arm megascore, or rate of FVC decline (high-quality evidence). One trial investigated monthly decline in the ALSFRS and quality of life measured using the 12-Item Short Form Survey (SF-12) and found little or no difference between groups (moderate-quality evidence). The trials reported similar adverse events. Complaints that were clearly elevated in those taking gabapentin, based on analyses of the combined data, were light-headedness, drowsiness, and limb swelling (high-quality evidence). Fatigue and falls occurred more frequently with gabapentin than with placebo in one trial, but when we combined the data for fatigue from both trials, there was no clear difference between the groups. We assessed the overall risk of bias in the included trials as low. AUTHORS' CONCLUSIONS According to high-quality evidence, gabapentin is not effective in treating ALS. It does not extend survival, slow the rate of decline of muscle strength, respiratory function and, based on moderate-quality evidence, probably does not improve quality of life or slow monthly decline in the ALSFRS. Other GABA modulators have not been studied in randomized trials.
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Affiliation(s)
- Andrea Diana
- University of CagliariDepartment of Biomedical SciencesCitta Universitaria di Monserrato (Cagliari)Monserrato (Cagliari)Italy09042
| | - Rita Pillai
- University of CagliariDepartment of Biomedical SciencesCitta Universitaria di Monserrato (Cagliari)Monserrato (Cagliari)Italy09042
| | - Paolo Bongioanni
- University of PisaNeurorehabilitation Unit, Department of NeuroscienceVia Paradisa, 2PisaItaly56100
| | - Aidan G O'Keeffe
- University College LondonDepartment of Statistical Science1‐19 Torrington PlaceLondonUKWC1E 6BT
| | - Robert G Miller
- California Pacific Medical CenterForbes Norris ALS Research Center2324 Sacramento Street, Suite 150San FranciscoUSA94115
| | - Dan H Moore
- California Pacific Medical CenterResearch Institute475 Brannan St Suite 220San FranciscoCAUSA94107
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Weiss MD, Macklin EA, Simmons Z, Knox AS, Greenblatt DJ, Atassi N, Graves M, Parziale N, Salameh JS, Quinn C, Brown RH, Distad JB, Trivedi J, Shefner JM, Barohn RJ, Pestronk A, Swenson A, Cudkowicz ME. A randomized trial of mexiletine in ALS: Safety and effects on muscle cramps and progression. Neurology 2016; 86:1474-81. [PMID: 26911633 DOI: 10.1212/wnl.0000000000002507] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 10/26/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the safety and tolerability of mexiletine in a phase II double-blind randomized controlled trial of sporadic amyotrophic lateral sclerosis (SALS). METHODS Sixty participants with SALS from 10 centers were randomized 1:1:1 to placebo, mexiletine 300 mg/d, or mexiletine 900 mg/d and followed for 12 weeks. The primary endpoints were safety and tolerability. Secondary endpoints were pharmacokinetic study from plasma and CSF, ALS Functional Rating Scale-Revised (ALSFRS-R) score, slow vital capacity (SVC), and muscle cramp frequency and severity. RESULTS The only serious adverse event among active arm participants was one episode of imbalance. Thirty-two percent of participants receiving 900 mg of mexiletine discontinued study drug vs 5% on placebo (p = 0.026). Pharmacokinetic study demonstrated a peak plasma concentration 2 hours postdose and strong correlation between plasma and CSF (p < 0.001). Rates of decline of ALSFRS-R and SVC did not differ from placebo. Analysis of all randomized patients demonstrated significant reductions of muscle cramp frequency (300 mg: rate = 31% of placebo, p = 0.047; 900 mg: 16% of placebo, p = 0.002) and cramp intensity (300 mg: mean = 45% of placebo, p = 0.08; 900 mg: 25% of placebo, p = 0.005). CONCLUSIONS Mexiletine was safe at both doses and well-tolerated at 300 mg/d but adverse effects at 900 mg/d led to a high rate of discontinuation. Mexiletine treatment resulted in large dose-dependent reductions in muscle cramp frequency and severity. No effect on rate of progression was detected, but clinically important differences could not be excluded in this small and short-duration study. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that mexiletine is safe when given daily to patients with amyotrophic lateral sclerosis at 300 and 900 mg and well-tolerated at the lower dose.
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Affiliation(s)
- Michael D Weiss
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City.
| | - Eric A Macklin
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Zachary Simmons
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Angela S Knox
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - David J Greenblatt
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Nazem Atassi
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Michael Graves
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Nicholas Parziale
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Johnny S Salameh
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Colin Quinn
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Robert H Brown
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Jane B Distad
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Jaya Trivedi
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Jeremy M Shefner
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Richard J Barohn
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Alan Pestronk
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Andrea Swenson
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
| | - Merit E Cudkowicz
- From the Department of Neurology (M.D.W., J.B.D.), University of Washington Medical Center, Seattle; Biostatistics Center (E.A.M.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (Z.S.), Penn State Hershey Medical Center, Hershey, PA; Department of Neurology (A.S.K., N.A., M.E.C.), Neurological Clinical Research Institute, Massachusetts General Hospital, Boston; Program in Pharmacology and Experimental Therapeutics (D.J.G.), Tufts University School of Medicine, Boston, MA; Department of Neurology (M.G., N.P.), UCLA Medical Center, Los Angeles, CA; Department of Neurology (J.S.S., C.Q., R.H.B.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurology (J.T.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (J.M.S.), Barrow Neurological Institute, Phoenix, AZ; Department of Neurology (R.J.B.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.P.), Washington University Medical Center, St. Louis, MO; and Department of Neurology (A.S.), University of Iowa Hospitals and Clinics, Iowa City
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7
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Clark R, Blizzard C, Dickson T. Inhibitory dysfunction in amyotrophic lateral sclerosis: future therapeutic opportunities. Neurodegener Dis Manag 2015; 5:511-25. [DOI: 10.2217/nmt.15.49] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
In amyotrophic lateral sclerosis, motor neuron hyperexcitability and inhibitory dysfunction is emerging as a potential causative link in the dysfunction and degeneration of the motoneuronal circuitry that characterizes the disease. Interneurons, as key regulators of excitability, may mediate much of this imbalance, yet we know little about the way in which inhibitory deficits perturb excitability. In this review, we explore inhibitory control of excitability and the potential contribution of altered inhibition to amyotrophic lateral sclerosis disease processes and vulnerabilities, identifying important windows of therapeutic opportunity and potential interventions, specifically targeting inhibitory control at key disease stages.
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Affiliation(s)
- Rosemary Clark
- Menzies Institute for Medical Research, University of Tasmania, Hobart TAS 7000, Australia
| | - Catherine Blizzard
- Menzies Institute for Medical Research, University of Tasmania, Hobart TAS 7000, Australia
| | - Tracey Dickson
- Menzies Institute for Medical Research, University of Tasmania, Hobart TAS 7000, Australia
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8
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Caress JB, Ciarlone SL, Sullivan EA, Griffin LP, Cartwright MS. Natural history of muscle cramps in amyotrophic lateral sclerosis. Muscle Nerve 2015; 53:513-7. [PMID: 26332705 DOI: 10.1002/mus.24892] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 06/19/2015] [Accepted: 08/31/2015] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Muscle cramping is a common symptom in amyotrophic lateral sclerosis (ALS) that lacks efficacious treatment. The natural history of this symptom is unknown, which hampers efforts to design optimal clinical trials. METHODS We surveyed early stage ALS patients about their experience with cramps each month by phone for up to 21 months. RESULTS Cramps developed in 95% of patients over the course of their disease. The number of cramps experienced by an individual varied widely from month-to-month and trended lower after the first year of illness (P = 0.26). Those with limb-onset and age >60 years had more cramps than bulbar-onset (P < 0.0001) and younger patients (P < 0.0001). CONCLUSIONS The high variability of the number of cramps experienced suggests that clinical trials will need to use crossover designs or large numbers of participants, even when the treatment effect is substantial.
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Affiliation(s)
- James B Caress
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephanie L Ciarlone
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | | | - Leah P Griffin
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael S Cartwright
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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9
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Zach N, Ennist DL, Taylor AA, Alon H, Sherman A, Kueffner R, Walker J, Sinani E, Katsovskiy I, Cudkowicz M, Leitner ML. Being PRO-ACTive: What can a Clinical Trial Database Reveal About ALS? Neurotherapeutics 2015; 12:417-23. [PMID: 25613183 PMCID: PMC4404433 DOI: 10.1007/s13311-015-0336-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Advancing research and clinical care, and conducting successful and cost-effective clinical trials requires characterizing a given patient population. To gather a sufficiently large cohort of patients in rare diseases such as amyotrophic lateral sclerosis (ALS), we developed the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) platform. The PRO-ACT database currently consists of >8600 ALS patient records from 17 completed clinical trials, and more trials are being incorporated. The database was launched in an open-access mode in December 2012; since then, >400 researchers from >40 countries have requested the data. This review gives an overview on the research enabled by this resource, through several examples of research already carried out with the goal of improving patient care and understanding the disease. These examples include predicting ALS progression, the simulation of future ALS clinical trials, the verification of previously proposed predictive features, the discovery of novel predictors of ALS progression and survival, the newly identified stratification of patients based on their disease progression profiles, and the development of tools for better clinical trial recruitment and monitoring. Results from these approaches clearly demonstrate the value of large datasets for developing a better understanding of ALS natural history, prognostic factors, patient stratification, and more. The increasing use by the community suggests that further analyses of the PRO-ACT database will continue to reveal more information about this disease that has for so long defied our understanding.
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10
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Atassi N, Berry J, Shui A, Zach N, Sherman A, Sinani E, Walker J, Katsovskiy I, Schoenfeld D, Cudkowicz M, Leitner M. The PRO-ACT database: design, initial analyses, and predictive features. Neurology 2014; 83:1719-25. [PMID: 25298304 DOI: 10.1212/wnl.0000000000000951] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To pool data from completed amyotrophic lateral sclerosis (ALS) clinical trials and create an open-access resource that enables greater understanding of the phenotype and biology of ALS. METHODS Clinical trials data were pooled from 16 completed phase II/III ALS clinical trials and one observational study. Over 8 million de-identified longitudinally collected data points from over 8,600 individuals with ALS were standardized across trials and merged to create the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) database. This database includes demographics, family histories, and longitudinal clinical and laboratory data. Mixed effects models were used to describe the rate of disease progression measured by the Revised ALS Functional Rating Scale (ALSFRS-R) and vital capacity (VC). Cox regression models were used to describe survival data. Implementing Bonferroni correction, the critical p value for 15 different tests was p = 0.003. RESULTS The ALSFRS-R rate of decline was 1.02 (±2.3) points per month and the VC rate of decline was 2.24% of predicted (±6.9) per month. Higher levels of uric acid at trial entry were predictive of a slower drop in ALSFRS-R (p = 0.01) and VC (p < 0.0001), and longer survival (p = 0.02). Higher levels of creatinine at baseline were predictive of a slower drop in ALSFRS-R (p = 0.01) and VC (p < 0.0001), and longer survival (p = 0.01). Finally, higher body mass index (BMI) at baseline was associated with longer survival (p < 0.0001). CONCLUSION The PRO-ACT database is the largest publicly available repository of merged ALS clinical trials data. We report that baseline levels of creatinine and uric acid, as well as baseline BMI, are strong predictors of disease progression and survival.
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Affiliation(s)
- Nazem Atassi
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA.
| | - James Berry
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - Amy Shui
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - Neta Zach
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - Alexander Sherman
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - Ervin Sinani
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - Jason Walker
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - Igor Katsovskiy
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - David Schoenfeld
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - Merit Cudkowicz
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
| | - Melanie Leitner
- From the Neurological Clinical Research Institute (NCRI), Department of Neurology (N.A., J.B., A. Sherman, E.S., J.W., I.K., M.C.), and the Biostatistics Center (A. Shui, D.S.), Massachusetts General Hospital, Boston; and Prize4Life (N.Z., M.L.), Cambridge, MA
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11
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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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12
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Kobeleva X, Petri S. Barriers to novel therapeutics in amyotrophic lateral sclerosis. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Amyotrophic lateral sclerosis is a devastating neurodegenerative condition primarily involving the motor system in the cerebral cortex, brain stem and spinal cord, but can, in later disease stages, also affect distinct extramotor brain regions. In this article, we discuss the prevalent barriers, including clinical and genetic variability of amyotrophic lateral sclerosis, frailty of the current mouse model and inadequateness of clinical trials, in the search for novel therapeutics. Approaches in terms of understanding the pathogenesis, and the search for biomarkers to initiate early or even presymptomatic treatment and monitor treatment effects are highlighted.
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Affiliation(s)
- Xenia Kobeleva
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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13
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Choudry RB, Cudkowicz ME. Clinical Trials in Amyotrophic Lateral Sclerosis: The Tenuous Past and the Promising Future. J Clin Pharmacol 2013; 45:1334-44. [PMID: 16291708 DOI: 10.1177/0091270005282631] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The past decade of research in amyotrophic lateral sclerosis has contributed to a greater understanding of the disease process, the development of relevant animal models, and the identification of several therapeutic approaches that may delay disease progression. Completed and ongoing clinical trials and the process of selecting drugs for clinical trials are presented.
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Affiliation(s)
- Rabia B Choudry
- Neurology Clinical Trials Unit, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, GRB 1256, Boston, MA 02114, USA.
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14
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Progress in therapy development for amyotrophic lateral sclerosis. Neurol Res Int 2012; 2012:187234. [PMID: 22830014 PMCID: PMC3399448 DOI: 10.1155/2012/187234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/25/2012] [Indexed: 12/13/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that cannot be slowed substantially using any currently-available clinical tools. Through decades of studying sporadic and familial ALS (SALS and FALS), researchers are coming to understand ALS as a complex syndrome with diverse genetic and environmental etiologies. It is know appreciated that motor neuron degeneration in ALS requires active (gain of function) and passive (loss of function) events to occur in non-neuronal cells, especially astrocytes and microglia. These neuroinflammatory processes produce paracrine factors that detrimentally affect motor neurons, precipitating protein aggregation and compromising cytoskeletal integrity. The result is a loss of neuronal homeostasis and progressive die-back of motor axons culminating in death of the afflicted motor neurons. This review will discuss experimental therapeutics that have been tested in murine ALS models, with an emphasis on those that have progressed to human clinical trials. Reasons will be considered for the frequent failure of preclinical successes to translate into positive clinical outcomes. Finally, this review will explore current trends in experimental therapeutics for ALS with emphasis on the emerging interest in axon guidance signaling pathways as novel targets for pharmacological support of neural cytoskeletal structure and function in order to slow ALS.
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15
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Therapy development for spinal muscular atrophy in SMN independent targets. Neural Plast 2012; 2012:456478. [PMID: 22701806 PMCID: PMC3369530 DOI: 10.1155/2012/456478] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 04/05/2012] [Accepted: 04/06/2012] [Indexed: 12/11/2022] Open
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive neurodegenerative disorder, leading to progressive muscle weakness, atrophy, and sometimes premature death. SMA is caused by mutation or deletion of the survival motor neuron-1 (SMN1) gene. An effective treatment does not presently exist. Since the severity of the SMA phenotype is inversely correlated with expression levels of SMN, the SMN-encoded protein, SMN is the most important therapeutic target for development of an effective treatment for SMA. In recent years, numerous SMN independent targets and therapeutic strategies have been demonstrated to have potential roles in SMA treatment. For example, some neurotrophic, antiapoptotic, and myotrophic factors are able to promote survival of motor neurons or improve muscle strength shown in SMA mouse models or clinical trials. Plastin-3, cpg15, and a Rho-kinase inhibitor regulate axonal dynamics and might reduce the influences of SMN depletion in disarrangement of neuromuscular junction. Stem cell transplantation in SMA model mice resulted in improvement of motor behaviors and extension of survival, likely from trophic support. Although most therapies are still under investigation, these nonclassical treatments might provide an adjunctive method for future SMA therapy.
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16
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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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Wadman RI, Bosboom WMJ, van der Pol WL, van den Berg LH, Wokke JHJ, Iannaccone ST, Vrancken AFJE. Drug treatment for spinal muscular atrophy types II and III. Cochrane Database Syst Rev 2012:CD006282. [PMID: 22513940 DOI: 10.1002/14651858.cd006282.pub4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is caused by degeneration of anterior horn cells, which leads to progressive muscle weakness. Children with SMA type II do not develop the ability to walk without support and have a shortened life expectancy, whereas children with SMA type III develop the ability to walk and have a normal life expectancy. There are no known efficacious drug treatments that influence the disease course of SMA. This is an update of a review first published in 2009. OBJECTIVES To evaluate whether drug treatment is able to slow or arrest the disease progression of SMA types II and III and to assess if such therapy can be given safely. Drug treatment for SMA type I is the topic of a separate updated Cochrane review. SEARCH METHODS We searched the Cochrane Neuromuscular Disease Group Specialized Register (8 March 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE (January 1991 to February 2011), EMBASE (January 1991 to February 2011) and ISI Web of Knowledge (January 1991 to March 8 2011). We also searched clinicaltrials.gov to identify as yet unpublished trials (8 March 2011). SELECTION CRITERIA We sought all randomised or quasi-randomised trials that examined the efficacy of drug treatment for SMA types II and III. Participants had to fulfil the clinical criteria and have a deletion or mutation of the survival motor neuron 1 (SMN1) gene (5q11.2-13.2) that was confirmed by genetic analysis.The primary outcome measure was to be change in disability score within one year after the onset of treatment. Secondary outcome measures within one year after the onset of treatment were to be change in muscle strength, ability to stand or walk, change in quality of life, time from the start of treatment until death or full time ventilation and adverse events attributable to treatment during the trial period. DATA COLLECTION AND ANALYSIS Two authors independently reviewed and extracted data from all potentially relevant trials. Pooled relative risks and pooled standardised mean differences were to be calculated to assess treatment efficacy. Risk of bias was systematically analysed. MAIN RESULTS Six randomised placebo-controlled trials on treatment for SMA types II and III were found and included in the review: the four in the original review and two trials added in this update. The treatments were creatine (55 participants), phenylbutyrate (107 participants), gabapentin (84 participants), thyrotropin releasing hormone (9 participants), hydroxyurea (57 participants), and combination therapy with valproate and acetyl-L-carnitine (61 participants). None of these studies were completely free of bias. All studies had adequate blinding, sequence generation and reports of primary outcomes.None of the included trials showed any statistically significant effects on the outcome measures in participants with SMA types II and III. One participant died due to suffocation in the hydroxyurea trial and one participant died in the creatine trial. No participants in any of the other four trials died or reached the state of full time ventilation. Serious side effects were infrequent. AUTHORS' CONCLUSIONS There is no proven efficacious drug treatment for SMA types II and III.
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Affiliation(s)
- Renske I Wadman
- Department of Neurology, University Medical Center Utrecht, Utrecht, Netherlands.
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Turner MR, Kiernan MC. Does interneuronal dysfunction contribute to neurodegeneration in amyotrophic lateral sclerosis? ACTA ACUST UNITED AC 2012; 13:245-50. [PMID: 22424125 DOI: 10.3109/17482968.2011.636050] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is typically regarded as a sporadic neurodegenerative disorder that results in a catastrophic failure of the motor system, with characteristically variable involvement of upper and lower motor neuronal populations. A wide range of evidence from clinical, histological, genetic, neurophysiological, neuroimaging and neuropsychological studies, suggests that a loss of central nervous system inhibitory neuronal influence is a contributing factor in ALS pathogenesis. This loss of inhibitory function points intuitively to an 'interneuronopathy', with natural differences in cortical and spinal inhibitory networks reflected in the hitherto unexplained variable compartmentalization of pathology within upper and lower motor neuron populations. An excitotoxic final common pathway might then result from unopposed glutamatergic activity. If correct, therapies aimed specifically at supporting interneuronal function may provide a novel therapeutic strategy.
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Affiliation(s)
- Martin R Turner
- Oxford University Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK.
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Morren JA, Galvez-Jimenez N. Current and prospective disease-modifying therapies for amyotrophic lateral sclerosis. Expert Opin Investig Drugs 2012; 21:297-320. [PMID: 22303913 DOI: 10.1517/13543784.2012.657303] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a devastating illness of unclear etiology affecting motor neurons. It causes unremitting muscle paralysis, atrophy and death usually within 3 - 5 years from diagnosis. The human and economic costs for those affected are sobering. To date, tremendous efforts have failed to find a cure. AREAS COVERED An extensive literature search was undertaken using Medline and the Cochrane Systematic Review and Clinical Trial databases. Riluzole and investigational ALS drugs are discussed. Riluzole is the only approved disease-modifying therapy despite its modest effect on survival. Recent research has produced promising agents aimed at better disease control if not a cure. This review discusses agents targeting neuronal glutamate excitotoxicity, protein misfolding and accumulation, autophagy, apoptosis, mitochondrial dysfunction, free radical oxidative injury, immunomodulation, mutant mRNA counteraction, muscle physiology, neurotrophic factors and stem cell applications. The challenges in ALS drug development are highlighted. EXPERT OPINION Riluzole should be used for patients with definite, probable, suspected or possible ALS by World Federation of Neurology diagnostic criteria. Systematic monitoring for hepatic dysfunction, neutropenia and other serious adverse effects should be done routinely as outlined. All ALS patients should consider genetic screening and enrollment in ALS trials guided by the data reviewed.
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Affiliation(s)
- John A Morren
- Department of Neurology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
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Wadman RI, Bosboom WM, van den Berg LH, Wokke JH, Iannaccone ST, Vrancken AF. Drug treatment for spinal muscular atrophy types II and III. Cochrane Database Syst Rev 2011:CD006282. [PMID: 22161400 DOI: 10.1002/14651858.cd006282.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is caused by degeneration of anterior horn cells, which leads to progressive muscle weakness. Children with SMA type II do not develop the ability to walk without support and have a shortened life expectancy, whereas children with SMA type III develop the ability to walk and have a normal life expectancy. There are no known efficacious drug treatments that influence the disease course of SMA. This is an update of a review first published in 2009. OBJECTIVES To evaluate whether drug treatment is able to slow or arrest the disease progression of SMA types II and III and to assess if such therapy can be given safely. Drug treatment for SMA type I is the topic of a separate updated Cochrane review. SEARCH METHODS We searched the Cochrane Neuromuscular Disease Group Specialized Register (8 March 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE (January 1991 to February 2011), EMBASE (January 1991 to February 2011) and ISI Web of Knowledge (January 1991 to March 8 2011). We also searched clinicaltrials.gov to identify as yet unpublished trials (8 March 2011). SELECTION CRITERIA We sought all randomised or quasi-randomised trials that examined the efficacy of drug treatment for SMA types II and III. Participants had to fulfil the clinical criteria and have a deletion or mutation of the survival motor neuron 1 (SMN1) gene (5q11.2-13.2) that was confirmed by genetic analysis.The primary outcome measure was to be change in disability score within one year after the onset of treatment. Secondary outcome measures within one year after the onset of treatment were to be change in muscle strength, ability to stand or walk, change in quality of life, time from the start of treatment until death or full time ventilation and adverse events attributable to treatment during the trial period. DATA COLLECTION AND ANALYSIS Two authors independently reviewed and extracted data from all potentially relevant trials. Pooled relative risks and pooled standardised mean differences were to be calculated to assess treatment efficacy. Risk of bias was systematically analysed. MAIN RESULTS Six randomised placebo-controlled trials on treatment for SMA types II and III were found and included in the review: the four in the original review and two trials added in this update. The treatments were creatine (55 participants), phenylbutyrate (107 participants), gabapentin (84 participants), thyrotropin releasing hormone (9 participants), hydroxyurea (57 participants), and combination therapy with valproate and acetyl-L-carnitine (61 participants). None of these studies were completely free of bias. All studies had adequate blinding, sequence generation and reports of primary outcomes.None of the included trials showed any statistically significant effects on the outcome measures in participants with SMA types II and III. One participant died due to suffocation in the hydroxyurea trial and one participant died in the creatine trial. No participants in any of the other four trials died or reached the state of full time ventilation. Serious side effects were infrequent. AUTHORS' CONCLUSIONS There is no proven efficacious drug treatment for SMA types II and III.
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Affiliation(s)
- Renske I Wadman
- Department of Neurology, University Medical Center Utrecht, Rudolf Magnus Institute for Neuroscience, Universiteitsweg 100, Utrecht, Netherlands, 3584 CG
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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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Burnett BG, Crawford TO, Sumner CJ. Emerging treatment options for spinal muscular atrophy. Curr Treat Options Neurol 2011; 11:90-101. [PMID: 19210911 DOI: 10.1007/s11940-009-0012-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The motor neuron disease spinal muscular atrophy (SMA) is one of the leading genetic killers of infants worldwide. SMA is caused by mutation of the survival motor neuron 1 (SMN1) gene and deficiency of the survival motor neuron (SMN) protein. All patients retain one or more copies of the SMN2 gene, which (by producing a small amount of the SMN protein) rescues embryonic lethality and modifies disease severity. Rapid progress continues in dissecting the cellular functions of the SMN protein, but the mechanisms linking SMN deficiency with dysfunction and loss of functioning motor units remain poorly defined. Clinically, SMA should to be distinguished from other neuromuscular disorders, and the diagnosis can be readily confirmed with genetic testing. Quality of life and survival of SMA patients are improved with aggressive supportive care including optimized respiratory and nutritional care and management of scoliosis and contractures. Because SMA is caused by inadequate amounts of SMN protein, one aim of current SMA therapeutics development is to increase SMN protein levels in SMA patients by activating SMN2 gene expression and/or increasing levels of full-length SMN2 transcripts. Several potential therapeutic compounds are currently being studied in clinical trials in SMA patients.
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Affiliation(s)
- Barrington G Burnett
- Charlotte J. Sumner, MD 600 North Wolfe Street, Meyer 5-119b, Baltimore, MD 21287, USA.
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Abstract
BACKGROUND February 2009: The authors are aware of unpublished trial data for Gabapentin which could affect the results of this review. This information together with that from trials published since 2005, will be considered when this review is updated in 2009.Anticonvulsant drugs have been used in the management of pain since the 1960s. The clinical impression is that they are useful for chronic neuropathic pain, especially when the pain is lancinating or burning. OBJECTIVES To evaluate the analgesic effectiveness and adverse effects of gabapentin for pain management in clinical practice. SEARCH STRATEGY Randomised trials of gabapentin in acute, chronic or cancer pain were identified by MEDLINE (1966 to Nov 2004), EMBASE (1994 to Nov 2004), SIGLE (1980 to Jan 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2004). Additional studies were identified from the reference list of the retrieved papers, and by contacting investigators. Date of most recent search: January 2004. SELECTION CRITERIA Randomised trials reporting the analgesic effects of gabapentin in participants with subjective pain assessment as either the primary or a secondary outcome. DATA COLLECTION AND ANALYSIS Data were extracted by two independent review authors, and trials were quality scored. Numbers-needed-to-treat-to-benefit (NNTs) were calculated, where possible, from dichotomous data for effectiveness, adverse effects and drug-related study withdrawal. MAIN RESULTS Fourteen reports describing 15 studies of gabapentin were considered eligible (1468 participants). One was a study of acute pain. The remainder included the following conditions: post-herpetic neuralgia (two studies), diabetic neuropathy (seven studies), a cancer related neuropathic pain (one study) phantom limb pain (one study), Guillain Barré syndrome (one study), spinal chord injury pain (one study) and various neuropathic pains (one study).The study in acute post-operative pain (70 participants) showed no benefit for gabapentin compared to placebo for pain at rest.In chronic pain, the NNT for improvement in all trials with evaluable data is 4.3 (95% CI 3.5 to 5.7). Forty two percent of participants improved on gabapentin compared to 19% on placebo. The number needed to harm (NNH) for adverse events leading to withdrawal from a trial was not significant. Fourteen percent of participants withdrew from active arms compared to 10% in placebo arms. The NNH for minor harm was 3.7 (95% CI 2.4 to 5.4). The NNT for effective pain relief in diabetic neuropathy was 2.9 (95% CI 2.2 to 4.3) and for post herpetic neuralgia 3.9 (95% CI 3 to 5.7). AUTHORS' CONCLUSIONS There is evidence to show that gabapentin is effective in neuropathic pain. There is limited evidence to show that gabapentin is ineffective in acute pain.
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Affiliation(s)
| | - Henry J McQuay
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)West Wing (Level 6)John Radcliffe HospitalOxfordOxfordshireUKOX3 9DU
| | - Jayne Edwards
- UK Cochrane CentreTraining TeamNational Institute for Health ResearchSummertown Pavilion, Middle WayOxfordUKOX2 7LG
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Qureshi M, Schoenfeld DA, Paliwal Y, Shui A, Cudkowicz ME. The natural history of ALS is changing: Improved survival. ACTA ACUST UNITED AC 2009; 10:324-31. [DOI: 10.3109/17482960903009054] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Bedlack RS, Pastula DM, Hawes J, Heydt D. Open-label pilot trial of levetiracetam for cramps and spasticity in patients with motor neuron disease. ACTA ACUST UNITED AC 2009; 10:210-5. [PMID: 18821142 DOI: 10.1080/17482960802430773] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cramps and spasticity impair quality of life and function in patients with motor neuron diseases, and there are no proven treatments for these problems. We conducted a pilot trial to determine if treatment with levetiracetam was associated with a reduction in cramp severity, cramp frequency, tonic or phasic spasticity. We used an open-label repeated measures pilot trial of 20 patients, comparing cramp and spasticity scores over a 3-month baseline versus nine months on treatment. Cramp and spasticity scores were stable over a 3-month baseline. Shortly after starting levetiracetam, there was a significant reduction in cramp severity and frequency, which persisted for the duration of this year-long study. There was also a reduction in phasic but not tonic spasticity. Levetiracetam was well tolerated. Our results justify a placebo-controlled study of levetiracetam for treatment of cramps and spasticity in patients with motor neuron diseases, and suggest that this can be accomplished with a small number of subjects followed for a short time.
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Shefner JM. Muscle as a therapeutic target in amyotrophic lateral sclerosis. Exp Neurol 2009; 219:373-5. [DOI: 10.1016/j.expneurol.2009.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Revised: 06/17/2009] [Accepted: 06/18/2009] [Indexed: 12/12/2022]
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Vardeny O, Bromberg MB. The Use of Herbal Supplements and Alternative Therapies by Patients with Amyotrophic Lateral Sclerosis (ALS). ACTA ACUST UNITED AC 2009. [DOI: 10.1080/j157v05n03_03] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kaufmann P, Levy G, Montes J, Buchsbaum R, Barsdorf AI, Battista V, Arbing R, Gordon PH, Mitsumoto H, Levin B, Thompson JLP. Excellent inter‐rater, intra‐rater, and telephone‐administered reliability of the ALSFRS‐R in a multicenter clinical trial. ACTA ACUST UNITED AC 2009; 8:42-6. [PMID: 17364435 DOI: 10.1080/17482960600888156] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We wished to determine whether the Amyotrophic Lateral Sclerosis Functional Rating Scale-revised (ALSFRS-R) is reliable when used as primary outcome measure in a multicenter clinical trial. To establish inter-rater reliability, we randomly assigned 19 primary raters and 11 back-up raters to score nine amyotrophic lateral sclerosis (ALS) patients using the ALSFRS-R. To assess intra-rater reliability and reliability of telephone administration, we randomly assigned consecutive participants of the Clinical Trial of High Dose Coenzyme Q10 in ALS (QALS) to have in-person ALSFRS-R interviews at both screening and baseline visits (n=41 patients) or to have the ALSFRS-R interview by telephone at screening and in person at the baseline visit (n=27). An intraclass correlation coefficient (ICC) of reliability was calculated using a one-way random effects analysis of variance model. In the inter-rater reliability assessment, the primary raters performed 54 ratings on nine patients with ICC=0.93 (95% CI 0.84-0.98). For back-up raters, 32 ratings on nine patients resulted in ICC=0.93 (95% CI 0.82-0.98). The intra-rater reliability for in-person interviews was ICC = 0.95 (95% CI 0.92-0.98). The reliability of telephone administration compared to in-person interviews was ICC=0.97 (95% CI 0.93-0.98). We conclude that the ALSFRS-R shows excellent inter- and intra-rater reliability, and reliability of telephone administration when used as primary outcome measure in a multicenter ALS trial.
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Affiliation(s)
- Petra Kaufmann
- Department of Neurology, The Eleanor and Lou Gehrig MDA/ALS Research Center, College of Physicians and Surgeons, New York, NY, USA.
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Brooks BR, Juhasz-Poscine K, Waclawik A, Sanjak M, Belden D, Roelke K, Parnell J, Weasler C. Mosaic chemotherapy strategies for developing ALS/MND therapeutic approaches: Beta-2 adrenergic agonists. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/14660820050515700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Lanka V, Cudkowicz M. Therapy development for ALS: Lessons learned and path forward. ACTA ACUST UNITED AC 2009; 9:131-40. [DOI: 10.1080/17482960802112819] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Delivery of peptide and protein drugs over the blood-brain barrier. Prog Neurobiol 2009; 87:212-51. [PMID: 19395337 DOI: 10.1016/j.pneurobio.2008.12.002] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 11/11/2008] [Accepted: 12/17/2008] [Indexed: 12/12/2022]
Abstract
Peptide and protein (P/P) drugs have been identified as showing great promises for the treatment of various neurodegenerative diseases. A major challenge in this regard, however, is the delivery of P/P drugs over the blood-brain barrier (BBB). Intense research over the last 25 years has enabled a better understanding of the cellular and molecular transport mechanisms at the BBB, and several strategies for enhanced P/P drug delivery over the BBB have been developed and tested in preclinical and clinical-experimental research. Among them, technology-based approaches (comprising functionalized nanocarriers and liposomes) and pharmacological strategies (such as the use of carrier systems and chimeric peptide technology) appear to be the most promising ones. This review combines a comprehensive overview on the current understanding of the transport mechanisms at the BBB with promising selected strategies published so far that can be applied to facilitate enhanced P/P drug delivery over the BBB.
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Bosboom WMJ, Vrancken AFJE, van den Berg LH, Wokke JHJ, Iannaccone ST. Drug treatment for spinal muscular atrophy types II and III. Cochrane Database Syst Rev 2009:CD006282. [PMID: 19160275 DOI: 10.1002/14651858.cd006282.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is caused by degeneration of anterior horn cells, which leads to progressive muscle weakness. Children with SMA type II do not develop the ability to walk without support and have a shortened life expectancy, whereas children with SMA type III develop the ability to walk and have a normal life expectancy. There are no known efficacious drug treatments that influence the disease course of SMA. OBJECTIVES To evaluate if drug treatment is able to slow or arrest the disease progression of SMA type II and III, and to assess if such therapy can be given safely. Drug treatment for SMA type I will be the topic of a separate Cochrane review. SEARCH STRATEGY We searched the Cochrane Neuromuscular Disease Group Trials Register (September 30 2008), The Cochrane Library (Issue 3, 2008), MEDLINE (January 1966 to June 2008), EMBASE (January 1980 to June 2008), ISI (January 1988 to June 2008), and ACP Journal Club (January 1991 to June 2008). SELECTION CRITERIA We sought all randomized or quasi-randomized trials that examined the efficacy of drug treatment for SMA type II and III. Participants had to fulfil the clinical criteria and, in studies including genetic analysis to confirm the diagnosis, have a deletion or mutation of the SMN1 gene (5q11.2-13.2)The primary outcome measure was to be change in disability score within one year after the onset of treatment. Secondary outcome measures within one year after the onset of treatment were to be change in muscle strength, ability to stand or walk, change in quality of life, time from the start of treatment until death or full time ventilation, and adverse events attributable to treatment during the trial period. DATA COLLECTION AND ANALYSIS Two authors independently reviewed and extracted data from all potentially relevant trials. Pooled relative risks and pooled weighted standardized mean differences were to be calculated to assess treatment efficacy MAIN RESULTS Four randomized placebo-controlled trials on treatment for SMA type II and III were found and included in the review. The treatments were creatine, phenylbutyrate, gabapentin and thyrotropin releasing hormone. None of these trials showed any effect on the outcome measures in patients with SMA type II and III. None of the patients in any of the four trials died or reached the state of full time ventilation and serious side effects were infrequent. AUTHORS' CONCLUSIONS There is no proven efficacious drug treatment for SMA type II and III.
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Affiliation(s)
- Wendy M J Bosboom
- Department of Neurology, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, Amsterdam, Netherlands, 1061 AE.
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Benatar M, Kurent J, Moore DH. Treatment for familial amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2009; 2009:CD006153. [PMID: 19160266 PMCID: PMC7388919 DOI: 10.1002/14651858.cd006153.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND), is a rare neurodegenerative disease. Approximately 5% to 7% of ALS/MND patients report a family history of a similarly affected relative. Superoxide dismutase-1 gene mutations are the cause in about 20% of familial cases. In those with non-familial (sporadic) ALS/MND the cause is unknown. Also unknown is whether patients with familial and sporadic ALS/MND respond differently to treatment. OBJECTIVES To systematically review the literature and to answer the specific question: 'Is there a difference in the response to treatment between patients with sporadic and familial forms of ALS?' SEARCH STRATEGY In May 2006 we searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (January 1966 to May 2006) and EMBASE (January 1980 to May 2006) for randomized controlled trials (RCTs). Two review authors read the titles and abstracts of all articles and reviewed the full text of all possibly relevant articles. We scanned references of all included trials to identify additional relevant articles. For all trials eligible for inclusion we contacted the authors to request the necessary raw data. SELECTION CRITERIA Studies had to meet two criteria: (a) randomized controlled study design, and (b) inclusion of patients with both familial and sporadic ALS/MND. DATA COLLECTION AND ANALYSIS We attempted to contact authors of all trials that met inclusion criteria. We obtained data regarding ALS/MND type (sporadic versus familial), treatment assignment (active versus placebo), survival and ALS Functional Rating Scale scores for four large RCTs that included 822 sporadic and 41 familial ALS patients. We could not obtain data from 25 potentially eligible studies (17 trial authors could not be contacted and eight were unwilling to provide data). MAIN RESULTS There was no statistical evidence for a different response to treatment in patients with familial ALS/MND compared to those with sporadic ALS/MND. The pooled estimate of the hazard ratio for the interaction term (treatment x familial ALS) suggested a more beneficial response with respect to survival among patients with familial ALS/MND, but the result was not statistically significant. Estimates of the rate of decline on the ALS Functional Rating Scale also suggested a slightly better response to treatment among those with familial ALS/MND, but the result was not statistically significant. AUTHORS' CONCLUSIONS Future RCTs should document whether patients with familial ALS/MND are included and the presence or absence of a mutation in the superoxide dismutase-1 gene amongst those with familial ALS/MND.
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Affiliation(s)
- Michael Benatar
- Neurology Department, Emory University, Department of Neurology, Woodruff Memorial Building , Suite 6000, 100 Woodruff Circle, Atlanta, GA 30322, USA.
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Zoccolella S, Santamato A, Lamberti P. Current and emerging treatments for amyotrophic lateral sclerosis. Neuropsychiatr Dis Treat 2009; 5:577-95. [PMID: 19966906 PMCID: PMC2785861 DOI: 10.2147/ndt.s7788] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a relatively rare neurodegenerative disorder of both upper and lower motoneurons. Currently, the management of ALS is essentially symptoms-based, and riluzole, an antiglutamatergic agent, is the only drug for the treatment of ALS approved by the food and drug administration. OBJECTIVE We reviewed current literature concerning emerging treatments for amyotrophic lateral sclerosis. METHODS A Medline literature search was performed to identify all studies on ALS treatment published from January 1st, 1986 through August 31st, 2009. We selected papers concerning only disease-modifying therapy. RESULTS Forty-eight compounds were identified and reviewed in this study. CONCLUSIONS Riluzole is the only compound that demonstrated a beneficial effect on ALS patients, but with only modest increase in survival. Although several drugs showed effective results in the animal models for ALS, none of them significantly prolonged survival or improved quality of life of ALS patients. Several factors have been implicated in explaining the predominantly negative results of numerous randomized clinical trials in ALS, including methodological problems in the use of animal-drug screening, the lack of assessment of pharmacokinetic profile of the drugs, and methodological pitfalls of clinical trials in ALS patients.
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Affiliation(s)
- Stefano Zoccolella
- Azienda Ospedaliero-Universitaria Ospedali Riuniti, Department of Medical and Neurological Sciences, Clinic of Nervous System Diseases, University of Foggia, Italy.
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Abstract
Tremendous advances in our understanding of pathogenesis of amyotrophic lateral sclerosis (ALS) have provided a rich pipeline of drugs for clinical trialists. At least 32 unique compounds have been tested. Nevertheless, riluzole is currently the only treatment that prolongs survival. We present a critical overview of past clinical trials, how therapies are selected for testing in people, challenges with ALS clinical trial design and conduct, and ways to best move forward.
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Affiliation(s)
- Swati Aggarwal
- Department of Neurology, Massachusetts General Hospital, Neurology Clinical Trials Unit, Charlestown, Massachusetts 02129, USA.
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Abstract
Clinical trials in amyotrophic lateral sclerosis have significantly evolved over the last decade. New outcome measures have been developed that have reduced the sample size requirement as compared with survival studies. There has been increasing recognition that dose-ranging studies are crucial to full evaluation of experimental agents. While the requirements of late stage trials have not changed, many new designs have been suggested for earlier phase development. While no design achieves the perfect balance of sensitivity and efficiency, clinical trialists continue to work toward the goals of smaller and shorter trials so that more compounds can be studied concurrently.
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Van Den Bosch L, Robberecht W. Crosstalk between astrocytes and motor neurons: What is the message? Exp Neurol 2008; 211:1-6. [DOI: 10.1016/j.expneurol.2008.01.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 01/07/2008] [Accepted: 01/08/2008] [Indexed: 12/16/2022]
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Quels sont les traitements médicamenteux étiologiques? Rev Neurol (Paris) 2006. [DOI: 10.1016/s0035-3787(06)75190-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Quels sont les traitements medicamenteux symptomatiques? Rev Neurol (Paris) 2006. [DOI: 10.1016/s0035-3787(06)75192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Campana-Salort E. Évaluation des fonctions motrices dans la sclérose latérale amyotrophique (SLA). Rev Neurol (Paris) 2006. [DOI: 10.1016/s0035-3787(06)75177-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Yin RK, Schmidt RJ, Besag F. Aggregating Student Achievement Trends Across States With Different Tests: Using Standardized Slopes as Effect Sizes. ACTA ACUST UNITED AC 2006. [DOI: 10.1207/s15327930pje8102_3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Strong MJ. Amyotrophic lateral sclerosis: contemporary concepts in etiopathogenesis and pharmacotherapy. Expert Opin Investig Drugs 2006; 13:1593-614. [PMID: 15566317 DOI: 10.1517/13543784.13.12.1593] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Among the neurodegenerative diseases associated with ageing, amyotrophic lateral sclerosis (ALS) remains the most devastating. The disease inexorably progresses, the vast majority of pharmacotherapies have failed to modify the disease course, death ensues on average within 5 years of symptom onset and increasing numbers of individuals are afflicted with the disease. However, significant advances in our understanding of the natural history of ALS and of the fundamental nature of the biological defect underlying motor neuron degeneration have been gained, providing hope for the development of novel pharmacotherapies for ALS. Among these is the recognition that ALS is a biologically heterogeneous disorder in which genetics, environment and ageing all interrelate. The observation of clinical heterogeneity, with initial clinical manifestations serving as predictors of survivorship, is of considerable importance in designing therapeutic trials. The presence of frontotemporal dysfunction in a subset of patients has led to increased interest in the relationship between ALS and the degenerative tauopathies. Ultimately, the degenerating motor neurons do not die alone. The contribution of both microglia and astrocytes to the degenerative process are increasingly recognised. Understanding how these processes interrelate has become critical to understanding the pharmacotherapy of ALS and in the design of clinical trials. This review will highlight recent epidemiological and neurochemical advances in our understanding of ALS, and place them into the context of understanding the development of novel treatment avenues for this devastating disease.
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Affiliation(s)
- Michael J Strong
- Department of Clinical Neurological Sciences, University of Western Ontario, The Robarts Research Institute, London, Canada.
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de Carvalho M, Costa J, Swash M. Clinical trials in ALS: a review of the role of clinical and neurophysiological measurements. ACTA ACUST UNITED AC 2006; 6:202-12. [PMID: 16319023 DOI: 10.1080/14660820510011997] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We have reviewed all the published clinical trials of ALS and, from those considered sufficiently large, and containing a control group, we have evaluated their methodology with regard to statistical power. This implies a critical analysis of the endpoint measurements. We have concluded that clinical endpoints used in clinical trials of ALS have frequently been insufficiently sensitive, non-linear, or even not intuitively highly relevant to the disease. We suggest that the ALS-FRS, perhaps also MUNE and the Neurophysiological Index, may be the best measures currently available. These techniques have complementary characteristics that allow them to be used to address different aspects of the disease and its treatment in various trials designs. In the past some trials may have failed to demonstrate a treatment effect because the chosen endpoint measures and the trial design were inappropriate.
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Fumagalli E, Bigini P, Barbera S, De Paola M, Mennini T. Riluzole, unlike the AMPA antagonist RPR119990, reduces motor impairment and partially prevents motoneuron death in the wobbler mouse, a model of neurodegenerative disease. Exp Neurol 2006; 198:114-28. [PMID: 16386734 DOI: 10.1016/j.expneurol.2005.11.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Revised: 09/07/2005] [Accepted: 11/18/2005] [Indexed: 01/28/2023]
Abstract
The wobbler mouse is one of the most useful models of motoneuron degeneration, characterized by selective motoneuronal death in the cervical spinal cord. We carried out two parallel studies in wobbler mice, comparing the anti-glutamatergic drug riluzole and the AMPA receptor antagonist RPR119990. Mice were treated with 40 mg/kg/day of riluzole or with 3 mg/kg/day of RPR119990 from the 4th to the 12th week of age. Here, we show that chronic treatment with riluzole improves motor behavior, prevents biceps muscle atrophy and decreases the amount of motoneuron loss in treated wobbler mice. Chronic treatment with the AMPA antagonist RPR119990 is ineffective in improving motor impairment, in reducing motoneuronal loss and muscular atrophy in treated mice. These results, together with the unchanged immunostaining for the AMPA receptor subunit GluR2 in wobbler mice, suggest that AMPA receptor-mediated injury is unlikely to be involved in neurodegeneration in wobbler disease, and that the protective effect of riluzole in wobbler mice seems to be independent of its anti-glutamatergic activity, as suggested in other models of neurodegeneration. Immunostaining of cervical spinal cord sections shows that in riluzole-treated wobbler mice BDNF expression is significantly increased in motoneurons with no changes in the high-affinity receptor Trk-B. Our data confirm that riluzole has beneficial effects in wobbler mice, and suggest that these effects could be associated to the increased levels of the neurotrophic and neuroprotective factor BDNF.
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Affiliation(s)
- Elena Fumagalli
- Laboratory of Receptor Pharmacology, Mario Negri Institute for Pharmacological Research, Via Eritrea 62, 20157 Milan, Italy
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Abstract
BACKGROUND Anticonvulsant drugs have been used in the management of pain since the 1960s. The clinical impression is that they are useful for chronic neuropathic pain, especially when the pain is lancinating or burning. OBJECTIVES To evaluate the analgesic effectiveness and adverse effects of gabapentin for pain management in clinical practice. SEARCH STRATEGY Randomised trials of gabapentin in acute, chronic or cancer pain were identified by MEDLINE (1966-Nov 2004), EMBASE (1994-Nov 2004), SIGLE (1980-Jan 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 4, 2004). Additional reports were identified from the reference list of the retrieved papers, and by contacting investigators. Date of most recent search: January 2004. SELECTION CRITERIA Randomised trials reporting the analgesic effects of gabapentin in patients, with subjective pain assessment as either the primary or a secondary outcome. DATA COLLECTION AND ANALYSIS Data were extracted by two independent reviewers, and trials were quality scored. Numbers-needed-to-treat (NNTs) were calculated, where possible, from dichotomous data for effectiveness, adverse effects and drug-related study withdrawal. MAIN RESULTS Fourteen reports describing 15 studies of gabapentin were considered eligible (1468 participants). One was a study of acute pain. The remainder included the following conditions: post-herpetic neuralgia (two studies), diabetic neuropathy (seven studies), a cancer related neuropathic pain (one study) phantom limb pain (one study), Guillain Barré syndrome (one study) , spinal chord injury pain (one study) and various neuropathic pains (one study). The study in acute post-operative pain (70 participants) showed no benefit for gabapentin compared to placebo for pain at rest. In chronic pain, the NNT for improvement in all trials with evaluable data is 4.3 (95%CI 3.5-5.7). Forty two percent of participants improved on gabapentin compared to 19% on placebo. The number needed to harm(NNH) for adverse events leading to withdrawal from a trial was not significant. Fourteen percent of participants withdrew from active arms compared to 10% in placebo arms. The NNH for minor harm was 3.7 (95% CI 2.4 to 5.4). The NNT for effective pain relief in diabetic neuropathy was 2.9 (95% CI 2.2 to 4.3) and for post herpetic neuralgia 3.9 (95% CI 3 to 5.7). AUTHORS' CONCLUSIONS There is evidence to show that gabapentin is effective in neuropathic pain. There is limited evidence to show that gabapentin is ineffective in acute pain.
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Affiliation(s)
- P J Wiffen
- Pain Research Unit, Churchill Hospital, Old Road, Headington, Oxford, UK, OX3 7LJ.
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Winhammar JMC, Rowe DB, Henderson RD, Kiernan MC. Assessment of disease progression in motor neuron disease. Lancet Neurol 2005; 4:229-38. [PMID: 15778102 DOI: 10.1016/s1474-4422(05)70042-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Motor neuron disease (MND) is characterised by progressive deterioration of the corticospinal tract, brainstem, and anterior horn cells of the spinal cord. There is no pathognomonic test for the diagnosis of MND, and physicians rely on clinical criteria-upper and lower motor neuron signs-for diagnosis. The presentations, clinical phenotypes, and outcomes of MND are diverse and have not been combined into a marker of disease progression. No single algorithm combines the findings of functional assessments and rating scales, such as those that assess quality of life, with biological markers of disease activity and findings from imaging and neurophysiological assessments. Here, we critically appraise developments in each of these areas and discuss the potential of such measures to be included in the future assessment of disease progression in patients with MND.
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Affiliation(s)
- Jennica M C Winhammar
- Department of Neurology and Multidisciplinary Motor Neurone Disease Clinic, Royal North Shore Hospital, NSW, Australia
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Abstract
There is currently no effective treatment for amyotrophic lateral sclerosis (ALS), a devastating disorder of the human nervous system that, due to motoneurone degeneration, causes progressive loss of muscle function and death. The relentless progression of ALS and the uniformly poor prognosis have been unhindered by a variety of therapeutic agents tested in previous clinical studies. Recently, two drugs, namely riluzole and recombinant human insulin-like growth factor-I (IGF-1), have been reported to benefit patients with ALS by improving survival or slowing disease progression. Several other drugs, such as gabapentin and various neurotrophic factors, are being investigated in on-going clinical trials. Therapeutic developments in ALS have been hampered by the fact that the precise cause of the disease remains unknown. In addition, there are considerable variations in disease related characteristics among patients, rendering accurate measurements of disease progression difficult. Advances in theories of pathogenesis, such as genetic factors, glutamate excitotoxicity, oxidative stress, autoimmune mechanism and cytoskeletal abnormality will help guide the development of future therapies. Newer approaches to therapy may include suitable glutamate antagonists, small molecules that augment neurotrophic factor function, and anti-oxidants. Combination therapy of effective agents should be considered.
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Affiliation(s)
- E C Lai
- Baylor College of Medicine, Houston Veterans Affairs Medical Center, 6550 Fannin, Suite 1801, Houston, Texas 77030, USA.
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Shefner JM. Multi-drug therapy in amyotrophic lateral sclerosis: combinations of multiple, untested drugs should not be used at this time. Muscle Nerve 2004; 30:676-8. [PMID: 15452839 DOI: 10.1002/mus.20187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jeremy M Shefner
- Department of Neurology, SUNY Upstate Medical University, Syracuse, New York, USA
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Cudkowicz M, Qureshi M, Shefner J. Measures and markers in Amyotrophic Lateral Sclerosis. Neurotherapeutics 2004. [DOI: 10.1007/bf03206611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disorder characterized by loss of spinal and cortical motor neurons, leading to progressive weakness and ultimately, death. Clinically, there appears to be an anatomic focus at disease onset, from which the disease then spreads. Because the focus of initial symptoms and the subsequent direction of spread can vary from patient to patient, disease monitoring is difficult, especially in a clinical trial, in which outcome measures must be identical and able to capture progression of all types. Thus, the search for markers of disease progression is especially important in ALS. Many approaches have been taken, from voluntary strength assessment and functional rating scales to physiological and pathological sampling of affected portions of nervous system. No proposed marker has been demonstrated to meet the desired criteria of biological meaning, sensitivity to disease progression, clear relationship to overall prognosis and survival, and ease of measurement. However, progress is being made in all of these regards.
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Affiliation(s)
- Merit Cudkowicz
- Neurology Clinical Trial Unit, Massachusetts General Hospital, Charlestown, Massachusetts 02129, USA.
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