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Genge A, Wainwright S, Vande Velde C. Amyotrophic lateral sclerosis: exploring pathophysiology in the context of treatment. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:225-236. [PMID: 38001557 DOI: 10.1080/21678421.2023.2278503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a complex, neurodegenerative disorder in which alterations in structural, physiological, and metabolic parameters act synergistically. Over the last decade there has been a considerable focus on developing drugs to slow the progression of the disease. Despite this, only four disease-modifying therapies are approved in North America. Although additional research is required for a thorough understanding of ALS, we have accumulated a large amount of knowledge that could be better integrated into future clinical trials to accelerate drug development and provide patients with improved treatment options. It is likely that future, successful ALS treatments will take a multi-pronged therapeutic approach, targeting different pathways, akin to personalized medicine in oncology. In this review, we discuss the link between ALS pathophysiology and treatments, looking at the therapeutic failures as learning opportunities that can help us refine and optimize drug development.
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Affiliation(s)
- Angela Genge
- Clinical Research Unit Director, ALS Clinic, Montreal, Quebec, Canada
| | - Steven Wainwright
- Amylyx Pharmaceuticals, Inc, Vancouver, British Columbia, Canada, and
| | - Christine Vande Velde
- CHUM Research Center, Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
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2
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Guareschi S, Ravasi M, Baldessari D, Pozzi S, Zaffino T, Melazzini M, Ambrosini A. The positive impact on translational research of Fondazione italiana di ricerca per la Sclerosi Laterale Amiotrofica (AriSLA), a non-profit foundation focused on amyotrophic lateral sclerosis. Convergence of ex-ante evaluation and ex-post outcomes when goals are set upfront. Front Res Metr Anal 2023; 8:1067981. [PMID: 37601533 PMCID: PMC10436489 DOI: 10.3389/frma.2023.1067981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 07/14/2023] [Indexed: 08/22/2023] Open
Abstract
Charities investing on rare disease research greatly contribute to generate ground-breaking knowledge with the clear goal of finding a cure for their condition of interest. Although the amount of their investments may be relatively small compared to major funders, the advocacy groups' clear mission promotes innovative research and aggregates highly motivated and mission-oriented scientists. Here, we illustrate the case of Fondazione italiana di ricerca per la Sclerosi Laterale Amiotrofica (AriSLA), the main Italian funding agency entirely dedicated to amyotrophic lateral sclerosis research. An international benchmark analysis of publications derived from AriSLA-funded projects indicated that their mean relative citation ratio values (iCite dashboard, National Institutes of Health, U.S.) were very high, suggesting a strong influence on the referring international scientific community. An interesting trend of research toward translation based on the "triangle of biomedicine" and paper citations (iCite) was also observed. Qualitative analysis on researchers' accomplishments was convergent with the bibliometric data, indicating a high level of performance of several working groups, lines of research that speak of progression toward clinical translation, and one study that has progressed from the investigation of cellular mechanisms to a Phase 2 international clinical trial. The key elements of the success of the AriSLA investment lie in: (i) the clear definition of the objectives (research with potential impact on patients, no matter how far), (ii) a rigorous peer-review process entrusted to an international panel of experts, (iii) diversification of the portfolio with ad hoc selection criteria, which also contributed to bringing new experts and younger scientists to the field, and (iv) a close interaction of AriSLA stakeholders with scientists, who developed a strong sense of belonging. Periodic review of the portfolio of investments is a vital practice for funding agencies. Sharing information between funding agencies about their own policies and research assessment methods and outcomes help guide the international debate on funding strategies and research directions to be undertaken, particularly in the field of rare diseases, where synergy is a relevant enabling factor.
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Affiliation(s)
| | | | | | | | | | | | - Anna Ambrosini
- Fondazione AriSLA ETS, Milan, Italy
- Fondazione Telethon ETS, Milan, Italy
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3
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El Ouaamari Y, Van den Bos J, Willekens B, Cools N, Wens I. Neurotrophic Factors as Regenerative Therapy for Neurodegenerative Diseases: Current Status, Challenges and Future Perspectives. Int J Mol Sci 2023; 24. [PMID: 36835277 DOI: 10.3390/ijms24043866] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 02/17/2023] Open
Abstract
Neurodegenerative diseases, including Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease (HD), multiple sclerosis (MS), spinal cord injury (SCI), and amyotrophic lateral sclerosis (ALS), are characterized by acute or chronic progressive loss of one or several neuronal subtypes. However, despite their increasing prevalence, little progress has been made in successfully treating these diseases. Research has recently focused on neurotrophic factors (NTFs) as potential regenerative therapy for neurodegenerative diseases. Here, we discuss the current state of knowledge, challenges, and future perspectives of NTFs with a direct regenerative effect in chronic inflammatory and degenerative disorders. Various systems for delivery of NTFs, such as stem and immune cells, viral vectors, and biomaterials, have been applied to deliver exogenous NTFs to the central nervous system, with promising results. The challenges that currently need to be overcome include the amount of NTFs delivered, the invasiveness of the delivery route, the blood-brain barrier permeability, and the occurrence of side effects. Nevertheless, it is important to continue research and develop standards for clinical applications. In addition to the use of single NTFs, the complexity of chronic inflammatory and degenerative diseases may require combination therapies targeting multiple pathways or other possibilities using smaller molecules, such as NTF mimetics, for effective treatment.
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Shefner JM, Bedlack R, Andrews JA, Berry JD, Bowser R, Brown R, Glass JD, Maragakis NJ, Miller TM, Rothstein JD, Cudkowicz ME. Amyotrophic Lateral Sclerosis Clinical Trials and Interpretation of Functional End Points and Fluid Biomarkers: A Review. JAMA Neurol 2022; 79:1312-1318. [PMID: 36251310 DOI: 10.1001/jamaneurol.2022.3282] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Importance Clinical trial activity in amyotrophic lateral sclerosis (ALS) is dramatically increasing; as a result, trial modifications have been introduced to improve efficiency, outcome measures have been reassessed, and considerable discussion about the level of data necessary to advance a drug to approval has occurred. This review discusses what recent pivotal studies can teach the community about these topics. Observations By restricting inclusion and exclusion criteria, recent trials have enrolled populations distinct from previous studies. This has led to efficacy signals being observed in studies that are smaller and shorter than was thought feasible previously. However, such trials raise questions about generalizability of results. Small trials with equivocal clinical results also raise questions about the data necessary to lead to regulatory approval. The ALS Functional Rating Scale-Revised remains the most commonly used primary outcome measure; this review discusses innovations in its use. Blood neurofilament levels can predict prognosis in ALS and may be a sensitive indicator of biologic effect; current knowledge does not yet support its use as a primary outcome. Conclusions and Relevance It is now possible to use specific inclusion criteria to recruit a homogeneous patient population progressing at a specific rate; this will likely impact trials in the future. Generalizability of results on limited populations remains a concern. Although clinical outcomes remain the most appropriate primary outcome measures, fluid markers reflecting biologically important processes will assume more importance as more is learned about the association between such markers and clinical end points. The benefit of use of analytic strategies, such as responder analyses, is still uncertain.
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Affiliation(s)
| | | | - Jinsy A Andrews
- The Neurological Institute, Columbia University, New York, New York
| | - James D Berry
- Healey & AMG Center ALS, Massachusetts General Hospital, Boston
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Malhotra HS, Singh BP, Kumar N, Garg RK, Kirubakaran R, Emsley HCA, Chhetri SK, Mulvaney CA, Villanueva G. Immunomodulatory treatment for amyotrophic lateral sclerosis/motor neuron disease. Hippokratia 2022. [DOI: 10.1002/14651858.cd013945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Hardeep S Malhotra
- Department of Neurology; King George's Medical University; Lucknow India
- Cochrane India-King George's Medical University, Lucknow affiliate; Lucknow India
| | - Balendra P Singh
- Cochrane India-King George's Medical University, Lucknow affiliate; Lucknow India
- Department of Prosthodontics; King George's Medical University; Lucknow India
| | - Neeraj Kumar
- Department of Neurology; King George's Medical University; Lucknow India
- Cochrane India-King George's Medical University, Lucknow affiliate; Lucknow India
| | - Ravindra K Garg
- Department of Neurology; King George's Medical University; Lucknow India
| | - Richard Kirubakaran
- Cochrane India-CMC Vellore Affiliate, Prof. BV Moses Centre for Evidence Informed Healthcare and Health Policy; Christian Medical College; Vellore India
| | - Hedley CA Emsley
- Department of Neurology; Lancashire Teaching Hospitals NHS Foundation Trust; Preston UK
- Lancaster Medical School; Lancaster University; Lancaster UK
| | - Suresh Kumar Chhetri
- Department of Neurology; Lancashire Teaching Hospitals NHS Foundation Trust; Preston UK
- Lancaster Medical School; Lancaster University; Lancaster UK
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Maghsoudi A, Zaringhalam J, Moosavi M, Eidi A; Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran, Department of Physiology, School of Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran, Nanobiology and Nanomedicine Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran, Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran. Intraperitoneal Carbamylated erythropoietin improves memory and hippocampal apoptosis in beta amyloid rat model of Alzheimer’s disease through stimulating autophagy and inhibiting necroptosis. Physiol Pharmacol 2021; 0:0-0. [DOI: 10.52547/phypha.26.4.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nguyen LM, Li Z, Yan X, Krzyzanski W. A quantitative systems pharmacology model of hyporesponsiveness to erythropoietin in rats. J Pharmacokinet Pharmacodyn 2021; 48:687-710. [PMID: 34100188 DOI: 10.1007/s10928-021-09762-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/04/2021] [Indexed: 12/29/2022]
Abstract
Recombinant human erythropoietin (rHuEPO) is effective in managing chronic kidney disease and chemotherapy-induced anemia. However, hyporesponsiveness to rHuEPO treatment was reported in about 10% of the patients. A decreased response in rats receiving a single or multiple doses of rHuEPO was also observed. In this study, we aimed to develop a quantitative systems pharmacology (QSP) model to examine hyporesponsiveness to rHuEPO in rats. Pharmacokinetic (PK) and pharmacodynamic (PD) data after a single intravenous dose of rHuEPO (100 IU/kg) was obtained from a previous study (Yan et al. in Pharm Res, 30:1026-1036, 2013) including rHuEPO plasma concentrations, erythroid precursors counts in femur bone marrow and spleen, reticulocytes (RETs), red blood cells (RBCs), and hemoglobin (HGB) in circulation. Parameter values were obtained from literature or calibrated with experimental data. Global sensitivity analysis and model-based simulations were performed to assess parameter sensitivity and hyporesponsiveness. The final QSP model adequately characterizes time courses of rHuEPO PK and nine PD endpoints in both control and treatment groups simultaneously. The model indicates that negative feedback regulation, neocytolysis, and depletion of erythroid precursors are major factors leading to hyporesponsiveness to rHuEPO treatment in rats.
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Affiliation(s)
- Ly Minh Nguyen
- Department of Pharmaceutical Sciences, The State University of New York at Buffalo, 370 Pharmacy Building, New York, 14214, USA
| | - Zhichuan Li
- Department of Pharmaceutical Sciences, The State University of New York at Buffalo, 370 Pharmacy Building, New York, 14214, USA
| | - Xiaoyu Yan
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, China
| | - Wojciech Krzyzanski
- Department of Pharmaceutical Sciences, The State University of New York at Buffalo, 370 Pharmacy Building, New York, 14214, USA.
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Bella ED, Bersano E, Antonini G, Borghero G, Capasso M, Caponnetto C, Chiò A, Corbo M, Filosto M, Giannini F, Spataro R, Lunetta C, Mandrioli J, Messina S, Monsurrò MR, Mora G, Riva N, Rizzi R, Siciliano G, Silani V, Simone I, Sorarù G, Tugnoli V, Verriello L, Volanti P, Furlan R, Nolan JM, Abgueguen E, Tramacere I, Lauria G. The unfolded protein response in amyotrophic later sclerosis: results of a phase 2 trial. Brain 2021; 144:2635-2647. [PMID: 33905493 PMCID: PMC8557337 DOI: 10.1093/brain/awab167] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/26/2021] [Accepted: 04/16/2021] [Indexed: 11/14/2022] Open
Abstract
Strong evidence suggests that endoplasmic reticulum (ER) stress plays a critical role in the pathogenesis of amyotrophic lateral sclerosis (ALS) through an altered regulation of proteostasis. Robust preclinical findings demonstrated that guanabenz selectively inhibits ER stress-induced eIF2α-phosphatase allowing misfolded protein clearance, reduces neuronal death and prolongs survival in in vitro and in vivo models. Its efficacy and safety in ALS patients are unknown. To address these issues, we conducted a multicentre, randomised, double-blind trial, with futility design. ALS patients with onset of symptoms within the previous 18 months were randomly assigned to receive in a 1:1:1:1 ratio guanabenz 64 mg, 32 mg, 16 mg or placebo daily for 6 months as add-on therapy to riluzole. The purpose of the placebo group blinding was safety but not efficacy. The primary outcome was the proportion of patients progressing to higher stages of disease in 6 months as measured by the ALS Milano-Torino staging compared to a historical cohort of 200 ALS patients. The secondary outcomes were the rate of decline in ALSFRS-R total score, slow vital capacity change, time to death, tracheotomy or permanent ventilation and serum light neurofilament level at 6 months. The primary analysis of efficacy was performed by intention-to-treat. Guanabenz 64 mg and 32 mg arms, both alone and combined, reached the primary hypothesis of non-futility with proportions of patients who progressed to higher stage of disease at 6 months significantly lower than that expected under the hypothesis of non-futility and significantly lower difference in the median rate of change of the ALSFRS-R total score. This effect was driven by patients with bulbar onset, none of whom (0/18) progressed to a higher stage of disease at 6 months compared with those in guanabenz 16 mg (4/8; 50%), historical cohort alone (21/49; 43%; p = 0.001) or plus placebo (25/60; 42%; p = 0.001). The proportion of patients who experienced at least one adverse event was higher in any guanabenz arm than in the placebo arm, with higher dosing arms having significantly higher proportion of drug-related side effects and the 64 mg arm significantly higher drop-out rate. The number of serious adverse events did not significantly differ between guanabenz arms and placebo. Our findings indicate that a larger trial with a molecule targeting the UPR pathway without the alpha-2 adrenergic related side-effect profile of guanabenz is warranted.
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Affiliation(s)
- Eleonora Dalla Bella
- 3rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Enrica Bersano
- 3rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Giovanni Antonini
- NESMOS Department, Neuromuscolar Disease Unit, Sant'Andrea Hospital and University of Rome "Sapienza", Rome, Italy
| | | | | | | | - Adriano Chiò
- ALS Centre "Rita Levi Montalcini", Department of Neuroscience, University of Turin, Turin, Italy.,Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Massimo Corbo
- Department of Neurorehabilitaton, Casa Cura Policlinico, Milan, Italy
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili Brescia and NeMO-Brescia Clinical Centre for Neuromuscular Diseases, Brescia, Italy
| | - Fabio Giannini
- Department of Medical and Surgery Sciences and Neurosciences, University of Siena, Italy
| | | | | | - Jessica Mandrioli
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Sonia Messina
- Unit of Neurology and Neuromuscular Disorders, Department of Clinical and Experimental Medicine and University of Messina, AOU Policlinico "G. Martino", Messina, Italy.,NEuroMuscular Omnicentre of Messina, University Hospital "G. Martino", Messina, Italy
| | | | | | - Nilo Riva
- Department of Neurology IRCCS "San Raffaele" Hospital, Milan, Italy
| | - Romana Rizzi
- Neurology Unit, Department of Neuro-Motor Diseases, Azienda Unità Sanitaria Locale, IRCCS of Reggio Emilia, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - Vincenzo Silani
- Department of Neurology-Stroke Unit and Laboratory of Neuroscience, Istituto Auxologico Italiano IRCCS, Milan, Italy.,Department of Pathophysiology and Transplantation, "Dino Ferrari" Centre and Centre for Neurotechnology and Brain Therapeutics, University of Milan, Milan, Italy
| | - Isabella Simone
- Department of Neurology and Psychiatry, University of Bari, Italy
| | - Gianni Sorarù
- Department of Neurosciences, University of Padua, Italy
| | - Valeria Tugnoli
- Department of Neuroscience and Rehabilitation, Division of Neurology, University Hospital of Ferrara, Ferrara, Italy
| | - Lorenzo Verriello
- Neurology Unit, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Paolo Volanti
- Intensive Neurorehabilitation Unit, ICS Maugeri IRCCS, Mistretta, Italy
| | - Roberto Furlan
- Clinical Neuroimmunology Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - John M Nolan
- Drew University, Caspersen School of Graduate Studies, Madison, NJ, USA
| | | | - Irene Tramacere
- Scientific Directorate, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Giuseppe Lauria
- 3rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy.,Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
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Cappella M, Pradat PF, Querin G, Biferi MG. Beyond the Traditional Clinical Trials for Amyotrophic Lateral Sclerosis and The Future Impact of Gene Therapy. J Neuromuscul Dis 2021; 8:25-38. [PMID: 33074186 PMCID: PMC7902976 DOI: 10.3233/jnd-200531] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating and incurable motor neuron (MN) disorder affecting both upper and lower MNs. Despite impressive advances in the understanding of the disease’s pathological mechanism, classical pharmacological clinical trials failed to provide an efficient cure for ALS over the past twenty years. Two different gene therapy approaches were recently approved for the monogenic disease Spinal muscular atrophy, characterized by degeneration of lower MNs. This milestone suggests that gene therapy-based therapeutic solutions could be effective for the treatment of ALS. This review summarizes the possible reasons for the failure of traditional clinical trials for ALS. It provides then a focus on the advent of gene therapy approaches for hereditary forms of ALS. Specifically, it describes clinical use of antisense oligonucleotides in three familial forms of ALS, caused by mutations in SOD1, C9orf72 and FUS genes, respectively.. Clinical and pre-clinical studies based on AAV-mediated gene therapy approaches for both familial and sporadic ALS cases are presented as well. Overall, this overview highlights the potential of gene therapy as a transforming technology that will have a huge impact on treatment perspective for ALS patients and on the design of future clinical trials.
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Affiliation(s)
- Marisa Cappella
- INSERM, Institute of Myology, Centre of Research in Myology, Sorbonne Université, Paris, France
| | - Pierre-François Pradat
- INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, Sorbonne Université, Paris, France.,APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre référent SLA, Paris, France.,Northern Ireland Centre for Stratified Medicine, Biomedical Sciences Research Institute Ulster University, C-TRIC, Altnagelvin Hospital, Derry/Londonderry, United Kingdom
| | - Giorgia Querin
- INSERM, Institute of Myology, Centre of Research in Myology, Sorbonne Université, Paris, France.,Association Institut de Myologie, Plateforme Essais Cliniques Adultes, Paris, France.,APHP, Service de Neuromyologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Maria Grazia Biferi
- INSERM, Institute of Myology, Centre of Research in Myology, Sorbonne Université, Paris, France
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Wobst HJ, Mack KL, Brown DG, Brandon NJ, Shorter J. The clinical trial landscape in amyotrophic lateral sclerosis-Past, present, and future. Med Res Rev 2020; 40:1352-1384. [PMID: 32043626 PMCID: PMC7417284 DOI: 10.1002/med.21661] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/08/2019] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease marked by progressive loss of muscle function. It is the most common adult-onset form of motor neuron disease, affecting about 16 000 people in the United States alone. The average survival is about 3 years. Only two interventional drugs, the antiglutamatergic small-molecule riluzole and the more recent antioxidant edaravone, have been approved for the treatment of ALS to date. Therapeutic strategies under investigation in clinical trials cover a range of different modalities and targets, and more than 70 different drugs have been tested in the clinic to date. Here, we summarize and classify interventional therapeutic strategies based on their molecular targets and phenotypic effects. We also discuss possible reasons for the failure of clinical trials in ALS and highlight emerging preclinical strategies that could provide a breakthrough in the battle against this relentless disease.
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Affiliation(s)
- Heike J Wobst
- Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Boston, Massachusetts
| | - Korrie L Mack
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Merck & Co, Inc, Kenilworth, New Jersey
| | - Dean G Brown
- Hit Discovery, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Boston, Massachusetts
| | - Nicholas J Brandon
- Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Boston, Massachusetts
| | - James Shorter
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Barp A, Gerardi F, Lizio A, Sansone VA, Lunetta C. Emerging Drugs for the Treatment of Amyotrophic Lateral Sclerosis: A Focus on Recent Phase 2 Trials. Expert Opin Emerg Drugs 2020; 25:145-164. [PMID: 32456491 DOI: 10.1080/14728214.2020.1769067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disease involving both upper and lower motor neurons and resulting in increasing disability and death 3-5 years after onset of symptoms. Over 40 large clinical trials for ALS have been negative, except for Riluzole that offers a modest survival benefit, and Edaravone that modestly reduces disease progression in patients with specific characteristics. Thus, the discovery of efficient disease modifying therapy is an urgent need. AREAS COVERED Although the cause of ALS remains unclear, many studies have demonstrated that neuroinflammation, proteinopathies, glutamate-induced excitotoxicity, microglial activation, oxidative stress, and mitochondrial dysfunction may play a key role in the pathogenesis. This review highlights recent discoveries relating to these diverse mechanisms and their implications for the development of therapy. Ongoing phase 2 clinical trials aimed to interfere with these pathophysiological mechanisms are discussed. EXPERT OPINION This review describes the challenges that the discovery of an efficient drug therapy faces and how these issues may be addressed. With the continuous advances coming from basic research, we provided possible suggestions that may be considered to improve performance of clinical trials and turn ALS research into a 'fertile ground' for drug development for this devastating disease.
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Affiliation(s)
- Andrea Barp
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy.,Dept. Biomedical Sciences of Health, University of Milan , Milan, Italy
| | | | - Andrea Lizio
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy
| | - Valeria Ada Sansone
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy.,Dept. Biomedical Sciences of Health, University of Milan , Milan, Italy
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12
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Rey F, Balsari A, Giallongo T, Ottolenghi S, Di Giulio AM, Samaja M, Carelli S. Erythropoietin as a Neuroprotective Molecule: An Overview of Its Therapeutic Potential in Neurodegenerative Diseases. ASN Neuro 2020; 11:1759091419871420. [PMID: 31450955 PMCID: PMC6712762 DOI: 10.1177/1759091419871420] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Erythropoietin (EPO) is a cytokine mainly induced in hypoxia conditions. Its major production site is the kidney. EPO primarily acts on the erythroid progenitor cells in the bone marrow. More and more studies are highlighting its secondary functions, with a crucial focus on its role in the central nervous system. Here, EPO may interact with up to four distinct isoforms of its receptor (erythropoietin receptor [EPOR]), activating different signaling cascades with roles in neuroprotection and neurogenesis. Indeed, the EPO/EPOR axis has been widely studied in the neurodegenerative diseases field. Its potential therapeutic effects have been evaluated in multiple disorders, such as Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, spinal cord injury, as well as brain ischemia, hypoxia, and hyperoxia. EPO is showing great promise by counteracting secondary neuroinflammatory processes, reactive oxygen species imbalance, and cell death in these diseases. Multiple studies have been performed both in vitro and in vivo, characterizing the mechanisms through which EPO exerts its neurotrophic action. In some cases, clinical trials involving EPO have been performed, highlighting its therapeutic potential. Together, all these works indicate the potential beneficial effects of EPO.
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Affiliation(s)
- Federica Rey
- 1 Laboratory of Pharmacology, Department of Health Sciences, University of Milan, Italy
| | - Alice Balsari
- 1 Laboratory of Pharmacology, Department of Health Sciences, University of Milan, Italy
| | - Toniella Giallongo
- 1 Laboratory of Pharmacology, Department of Health Sciences, University of Milan, Italy
| | - Sara Ottolenghi
- 2 Laboratory of Biochemistry, Department of Health Sciences, University of Milan, Italy
| | - Anna M Di Giulio
- 1 Laboratory of Pharmacology, Department of Health Sciences, University of Milan, Italy.,3 Pediatric Clinical Research Center Fondazione "Romeo ed Enrica Invernizzi", University of Milan, Italy
| | - Michele Samaja
- 2 Laboratory of Biochemistry, Department of Health Sciences, University of Milan, Italy
| | - Stephana Carelli
- 1 Laboratory of Pharmacology, Department of Health Sciences, University of Milan, Italy.,3 Pediatric Clinical Research Center Fondazione "Romeo ed Enrica Invernizzi", University of Milan, Italy
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Filipi T, Hermanova Z, Tureckova J, Vanatko O, Anderova AM. Glial Cells-The Strategic Targets in Amyotrophic Lateral Sclerosis Treatment. J Clin Med 2020; 9:E261. [PMID: 31963681 DOI: 10.3390/jcm9010261] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurological disease, which is characterized by the degeneration of motor neurons in the motor cortex and the spinal cord and subsequently by muscle atrophy. To date, numerous gene mutations have been linked to both sporadic and familial ALS, but the effort of many experimental groups to develop a suitable therapy has not, as of yet, proven successful. The original focus was on the degenerating motor neurons, when researchers tried to understand the pathological mechanisms that cause their slow death. However, it was soon discovered that ALS is a complicated and diverse pathology, where not only neurons, but also other cell types, play a crucial role via the so-called non-cell autonomous effect, which strongly deteriorates neuronal conditions. Subsequently, variable glia-based in vitro and in vivo models of ALS were established and used for brand-new experimental and clinical approaches. Such a shift towards glia soon bore its fruit in the form of several clinical studies, which more or less successfully tried to ward the unfavourable prognosis of ALS progression off. In this review, we aimed to summarize current knowledge regarding the involvement of each glial cell type in the progression of ALS, currently available treatments, and to provide an overview of diverse clinical trials covering pharmacological approaches, gene, and cell therapies.
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Nowicka N, Juranek J, Juranek JK, Wojtkiewicz J. Risk Factors and Emerging Therapies in Amyotrophic Lateral Sclerosis. Int J Mol Sci 2019; 20:E2616. [PMID: 31141951 DOI: 10.3390/ijms20112616] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/17/2019] [Accepted: 05/24/2019] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal progressive neurodegenerative disease characterized by a permanent degeneration of both upper and lower motor neurons. Many different genes and pathophysiological processes contribute to this disease, however its exact cause remains unclear. Therefore, it is necessary to understand this heterogeneity to find effective treatments. In this review, we focus on selected environmental and genetic risk factors predisposing to ALS and highlight emerging treatments in ALS therapy. Of numerous defective genes associated with ALS, we focus on four principal genes that have been identified as definite causes of ALS: the SOD1 gene, C9orf72, TDP-43, as well as the recently identified TBK1. We also provide up-to-date information on selected environmental factors that have historically been considered as key players in ALS development and pathogenesis. In parallel to our survey of known risk factors, we also discuss emerging ALS stem cell therapies and experimental medicines currently undergoing phase II and III clinical trials.
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Abstract
Friedreich ataxia (FRDA) is a rare neurological disorder due to deficiency of the mitochondrial protein frataxin. Frataxin deficiency results in impaired mitochondrial function and iron deposition in affected tissues. Erythropoietin (EPO) is a cytokine which was mostly known as a key regulator of erythropoiesis until cumulative evidence showed additional neurotrophic and neuroprotective properties. These features offered the rationale for advancement of EPO in clinical trials in different neurological disorders in the past years, including FRDA. Several mechanisms of action of EPO may be beneficial in FRDA. First of all, EPO exposure results in frataxin upregulation in vitro and in vivo. By promoting erythropoiesis, EPO influences iron metabolism and induces shifts in iron pool which may ameliorate conditions of free iron excess and iron accumulation. Furthermore, EPO signaling is crucial for mitochondrial gene activation and mitochondrial biogenesis. Up to date nine clinical trials investigated the effects of EPO and derivatives in FRDA. The majority of these studies had a proof-of-concept design. Considering the natural history of FRDA, all of them were too short in duration and not powered for clinical changes. However, these studies addressed significant issues in the treatment with EPO, such as (1) the challenge of the dose finding, (2) stability of frataxin up-regulation, (3) continuous versus intermittent stimulation with EPO/regimen, or (4) tissue changes after EPO exposure in humans in vivo (muscle biopsy, brain imaging). Despite several clinical trials in the past, no treatment is available for the treatment of FRDA. Current lines of research focus on gene therapy, frataxin replacement strategies and on regulation of key metabolic checkpoints such as NrF2. Due to potential crosstalk with all these mechanisms, interventions on the EPO pathway still represent a valuable research field. The recent development of small EPO mimetics which maintain cytoprotective properties without erythropoietic action may open a new era in EPO research for the treatment of FRDA.
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Affiliation(s)
- Sylvia Boesch
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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16
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Kaji R, Imai T, Iwasaki Y, Okamoto K, Nakagawa M, Ohashi Y, Takase T, Hanada T, Shimizu H, Tashiro K, Kuzuhara S. Ultra-high-dose methylcobalamin in amyotrophic lateral sclerosis: a long-term phase II/III randomised controlled study. J Neurol Neurosurg Psychiatry 2019; 90:451-457. [PMID: 30636701 PMCID: PMC6581107 DOI: 10.1136/jnnp-2018-319294] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/20/2018] [Accepted: 11/27/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of intramuscular ultra-high-dose methylcobalamin in patients with amyotrophic lateral sclerosis (ALS). METHODS 373 patients with ALS (El Escorial definite or probable; laboratory-supported probable; duration ≤36 months) were randomly assigned to placebo, 25 mg or 50 mg of methylcobalamin groups. The primary endpoints were the time interval to primary events (death or full ventilation support) and changes in the Revised ALS Functional Rating Scale (ALSFRS-R) score from baseline to week 182. Efficacy was also evaluated using post-hoc analyses in patients diagnosed early (entered ≤12 months after symptom onset). RESULTS No significant differences were detected in either primary endpoint (minimal p value=0.087). However, post-hoc analyses of methylcobalamin-treated patients diagnosed and entered early (≤12 months' duration) showed longer time intervals to the primary event (p<0.025) and less decreases in the ALSFRS-R score (p<0.025) than the placebo group. The incidence of treatment-related adverse events was similar and low in all groups. CONCLUSION Although ultra-high-dose methylcobalamin did not show significant efficacy in the whole cohort, this treatment may prolong survival and retard symptomatic progression without major side effects if started early. TRIAL REGISTRATION NUMBER NCT00444613.
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Affiliation(s)
- Ryuji Kaji
- Department of Neurology, Tokushima University Hospital, Tokushima, Japan
| | - Takashi Imai
- National Hospital Organization Miyagi National Hospital, Sendai, Japan.,Tokushukai ALS Care Center, Tokushukai, Japan
| | - Yasuo Iwasaki
- Department of Neurology, Toho University Omori Medical Center, Tokyo, Japan
| | - Koichi Okamoto
- Department of Neurology, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Masanori Nakagawa
- North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuo Ohashi
- Department of Integrated Science and Engineering for Sustainable Society, Chuo University, Hachioji, Japan
| | | | | | | | - Kunio Tashiro
- Department of Neurology, Hokuyukai Neurological Hospital, Sapporo, Japan
| | - Shigeki Kuzuhara
- School of Nursing, Suzuka University of Medical Science, Suzuka, Japan
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Briones MRS, Snyder AM, Ferreira RC, Neely EB, Connor JR, Broach JR. A Possible Role for Platelet-Activating Factor Receptor in Amyotrophic Lateral Sclerosis Treatment. Front Neurol 2018; 9:39. [PMID: 29472887 PMCID: PMC5810282 DOI: 10.3389/fneur.2018.00039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/16/2018] [Indexed: 12/12/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is the third most prevalent neurodegenerative disease affecting upper and lower motor neurons. An important pathway that may lead to motor neuron degeneration is neuroinflammation. Cerebrospinal Fluids of ALS patients have increased levels of the inflammatory cytokine IL-18. Because IL-18 is produced by dendritic cells stimulated by the platelet-activating factor (PAF), a major neuroinflammatory mediator, it is expected that PAF is involved in ALS. Here we show pilot experimental data on amplification of PAF receptor (PAFR) mRNA by RT-PCR. PAFR is overexpressed, as compared to age matched controls, in the spinal cords of transgenic ALS SOD1-G93A mice, suggesting PAF mediation. Although anti-inflammatory drugs have been tested for ALS before, no clinical trial has been conducted using PAFR specific inhibitors. Therefore, we hypothesize that administration of PAFR inhibitors, such as Ginkgolide B, PCA 4248 and WEB 2086, have potential to function as a novel therapy for ALS, particularly in SOD1 familial ALS forms. Because currently there are only two approved drugs with modest effectiveness for ALS therapy, a search for novel drugs and targets is essential.
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Affiliation(s)
- Marcelo R S Briones
- Department of Health Informatics, Escola Paulista de Medicina, UNIFESP, São Paulo, São Paulo, Brazil.,Department of Biochemistry, Penn State College of Medicine, Institute for Personalized Medicine, Hershey, PA, United States
| | - Amanda M Snyder
- Department of Neurosurgery, Penn State College of Medicine, Hershey, PA, United States
| | - Renata C Ferreira
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, UNIFESP, São Paulo, São Paulo, Brazil
| | - Elizabeth B Neely
- Department of Neurosurgery, Penn State College of Medicine, Hershey, PA, United States
| | - James R Connor
- Department of Neurosurgery, Penn State College of Medicine, Hershey, PA, United States
| | - James R Broach
- Department of Biochemistry, Penn State College of Medicine, Institute for Personalized Medicine, Hershey, PA, United States
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Bella ED, Tramacere I, Antonini G, Borghero G, Capasso M, Caponnetto C, Chiò A, Corbo M, Eleopra R, Filosto M, Giannini F, Granieri E, Bella VL, Lunetta C, Mandrioli J, Mazzini L, Messina S, Monsurrò MR, Mora G, Riva N, Rizzi R, Siciliano G, Silani V, Simone I, Sorarù G, Volanti P, Lauria G. Protein misfolding, amyotrophic lateral sclerosis and guanabenz: protocol for a phase II RCT with futility design (ProMISe trial). BMJ Open 2017; 7:e015434. [PMID: 28801400 PMCID: PMC5724081 DOI: 10.1136/bmjopen-2016-015434] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Recent studies suggest that endoplasmic reticulum stress may play a critical role in the pathogenesis of amyotrophic lateral sclerosis (ALS) through an altered regulation of the proteostasis, the cellular pathway-balancing protein synthesis and degradation. A key mechanism is thought to be the dephosphorylation of eIF2α, a factor involved in the initiation of protein translation. Guanabenz is an alpha-2-adrenergic receptor agonist safely used in past to treat mild hypertension and is now an orphan drug. A pharmacological action recently discovered is its ability to modulate the synthesis of proteins by the activation of translational factors preventing misfolded protein accumulation and endoplasmic reticulum overload. Guanabenz proved to rescue motoneurons from misfolding protein stress both in in vitro and in vivo ALS models, making it a potential disease-modifying drug in patients. It is conceivable investigating whether its neuroprotective effects based on the inhibition of eIF2α dephosphorylation can change the progression of ALS. METHODS AND ANALYSES Protocolised Management In Sepsis is a multicentre, randomised, double-blind, placebo-controlled phase II clinical trial with futility design. We will investigate clinical outcomes, safety, tolerability and biomarkers of neurodegeneration in patients with ALS treated with guanabenz or riluzole alone for 6 months. The primary aim is to test if guanabenz can reduce the proportion of patients progressed to a higher stage of disease at 6 months compared with their baseline stage as measured by the ALS Milano-Torino Staging (ALS-MITOS) system and to the placebo group. Secondary aims are safety, tolerability and change in at least one biomarker of neurodegeneration in the guanabenz arm compared with the placebo group. Findings will provide reliable data on the likelihood that guanabenz can slow the course of ALS in a phase III trial. ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of IRCCS 'Carlo Besta Foundation' of Milan (Eudract no. 2014-005367-32 Pre-results) based on the Helsinki declaration.
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Affiliation(s)
- Eleonora Dalla Bella
- 3rd Neurology Unit and ALS Centre, IRCCS ‘Carlo Besta’ Neurological Institute, Milan, Italy
| | - Irene Tramacere
- Scientific Direction, IRCCS ‘Carlo Besta’ Neurological Institute, Milan, Italy
| | - Giovanni Antonini
- Neuromuscular Disease Unit, Sant’Andrea Hospital and University of Rome ‘Sapienza’, Rome, Italy
| | - Giuseppe Borghero
- Neurologic Unit, Monserrato University Hospital, Cagliari University, Cagliari, Italy
| | | | - Claudia Caponnetto
- Department of Neurosciences, Rehabilitatioņ Ophthalmology, Genetics, Mother and Child Disease, IRCCS University Hospital San Martino IST, Genova, Italy
| | - Adriano Chiò
- Department of Neurosciences, ALS Centre, ‘Rita Levi Montalcini’, University of Turin and Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation, Casa Cura Policlinico, Milan, Italy
| | - Roberto Eleopra
- Neurology Unit, S Maria della Misericordia University Hospital, Udine, Italy
| | | | - Fabio Giannini
- Department of Medical and Surgery Sciences and Neurosciences, University of Siena, Siena, Italy
| | | | | | | | - Jessica Mandrioli
- Department of Neurosciences, S Agostino-Estense Hospital, Modena, Italy
| | - Letizia Mazzini
- ALS Centre, Neurologic Clinic, Maggiore della Carità University Hospital, Novara;, Italy
| | | | | | - Gabriele Mora
- ALS Center, ‘Salvatore Maugeri’ Clinical-Scientific Institutes, Milan, Italy
| | - Nilo Riva
- Department of Neurology IRCCS ‘San Raffaele’ Hospital, Milan, Italy
| | - Romana Rizzi
- Neurology Unit, Department of Neuro-Motor Diseases, IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Vincenzo Silani
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano - Department of Pathophysiology and Transplantation, "Dino Ferrari" Center, Università degli Studi di Milano, Milan, Italy
| | - Isabella Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Gianni Sorarù
- Department of Neurosciences, University of Padua, Padua, Italy
| | - Paolo Volanti
- Intensive Neurorehabilitation Unit, IRCCS ‘Salvatore Maugeri’ Foundation, Mistretta, Italy
| | - Giuseppe Lauria
- 3rd Neurology Unit and ALS Centre, IRCCS ‘Carlo Besta’ Neurological Institute, Milan, Italy
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Masgrau R, Guaza C, Ransohoff RM, Galea E. Should We Stop Saying 'Glia' and 'Neuroinflammation'? Trends Mol Med 2017; 23:486-500. [PMID: 28499701 DOI: 10.1016/j.molmed.2017.04.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 12/15/2022]
Abstract
Central nervous system (CNS) therapeutics based on the theoretical framework of neuroinflammation have only barely succeeded. We argue that a problem may be the wrong use of the term 'neuroinflammation' as a distinct nosological entity when, based on recent evidence, it may not explain CNS disease pathology. Indeed, the terms 'neuroinflammation' and 'glia' could be obsolete. First, unbiased molecular profiling of CNS cell populations and individual cells reveals striking phenotypic heterogeneity in health and disease. Second, astrocytes, microglia, oligodendrocytes, and NG2 cells may contribute to higher-brain functions by performing actions beyond housekeeping. We propose that CNS diseases be viewed as failed circuits caused in part by disease-specific dysfunction of cells traditionally called 'glia', and hence, favor therapies promoting their functional recovery.
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Affiliation(s)
- Roser Masgrau
- Institut de Neurociències and Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Medicina, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Carmen Guaza
- Neuroimmunology Group, Functional and Systems Neurobiology Department, Instituto Cajal, Agencia Estatal del Consejo Superior de Investigaciones Científicas, Madrid, España; Spanish Network of Multiple Sclerosis, RETICS, Instituto de Salud Carlos III, Madrid, España
| | | | - Elena Galea
- Institut de Neurociències and Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Medicina, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain; ICREA, Pg. Lluís Companys 23, 08010 Barcelona, Spain.
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20
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Petrov D, Mansfield C, Moussy A, Hermine O. ALS Clinical Trials Review: 20 Years of Failure. Are We Any Closer to Registering a New Treatment? Front Aging Neurosci 2017; 9:68. [PMID: 28382000 PMCID: PMC5360725 DOI: 10.3389/fnagi.2017.00068] [Citation(s) in RCA: 271] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 03/06/2017] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating condition with an estimated mortality of 30,000 patients a year worldwide. The median reported survival time since onset ranges from 24 to 48 months. Riluzole is the only currently approved mildly efficacious treatment. Riluzole received marketing authorization in 1995 in the USA and in 1996 in Europe. In the years that followed, over 60 molecules have been investigated as a possible treatment for ALS. Despite significant research efforts, the overwhelming majority of human clinical trials (CTs) have failed to demonstrate clinical efficacy. In the past year, oral masitinib and intravenous edaravone have emerged as promising new therapeutics with claimed efficacy in CTs in ALS patients. Given their advanced phase of clinical development one may consider these drugs as the most likely near-term additions to the therapeutic arsenal available for patients with ALS. In terms of patient inclusion, CT with masitinib recruited a wider, more representative, less restrictive patient population in comparison to the only successful edaravone CT (edaravone eligibility criteria represents only 18% of masitinib study patients). The present manuscript reviews >50 CTs conducted in the last 20 years since riluzole was first approved. A special emphasis is put on the analysis of existing evidence in support of the clinical efficacy of edaravone and masitinib and the possible implications of an eventual marketing authorisation in the treatment of ALS.
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Affiliation(s)
| | | | | | - Olivier Hermine
- AB ScienceParis, France
- Imagine Institute, Necker HospitalParis, France
- INSERM, Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutic Implications, UMR 1163Paris, France
- Imagine Institute, Paris Descartes–Sorbonne Paris Cité UniversityParis, France
- CNRS, ERL 8254Paris, France
- Laboratory of Excellence GR-ExParis, France
- Equipe Labélisée par la Ligue Nationale Contre le CancerParis, France
- Department of Hematology, Necker HospitalParis, France
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21
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Lu H, Le WD, Xie YY, Wang XP. Current Therapy of Drugs in Amyotrophic Lateral Sclerosis. Curr Neuropharmacol 2016; 14:314-21. [PMID: 26786249 PMCID: PMC4876587 DOI: 10.2174/1570159x14666160120152423] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/16/2015] [Accepted: 10/09/2015] [Indexed: 12/12/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS), commonly termed as motor neuron disease (MND) in UK, is a chronically lethal disorder among the neurodegenerative diseases, meanwhile. ALS is basically irreversible and progressive deterioration of upper and lower motor neurons in the motor cortex, brain stem and medulla spinalis. Riluzole, used for the treatment of ALS, was demonstrated to slightly delay the initiation of respiratory dysfunction and extend the median survival of patients by a few months. In this study, the key biochemical defects were discussed, such as: mutant Cu/Zn superoxide dismutase, mitochondrial protectants, and anti-excitotoxic/ anti-oxidative / anti-inflammatory/ anti-apoptotic agents, so the related drug candidates that have been studied in ALS models would possibly be further used in ALS patients.
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Affiliation(s)
| | | | | | - Xiao-Ping Wang
- Department of Neurology, Shanghai First People's Hospital , Shanghai Jiao-Tong University, China, 200080.
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22
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Blasco H, Patin F, Andres CR, Corcia P, Gordon PH. Amyotrophic Lateral Sclerosis, 2016: existing therapies and the ongoing search for neuroprotection. Expert Opin Pharmacother 2016; 17:1669-82. [PMID: 27356036 DOI: 10.1080/14656566.2016.1202919] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS), one in a family of age-related neurodegenerative disorders, is marked by predominantly cryptogenic causes, partially elucidated pathophysiology, and elusive treatments. The challenges of ALS are illustrated by two decades of negative drug trials. AREAS COVERED In this article, we lay out the current understanding of disease genesis and physiology in relation to drug development in ALS, stressing important accomplishments and gaps in knowledge. We briefly consider clinical ALS, the ongoing search for biomarkers, and the latest in trial design, highlighting major recent and ongoing clinical trials; and we discuss, in a concluding section on future directions, the prion-protein hypothesis of neurodegeneration and what steps can be taken to end the drought that has characterized drug discovery in ALS. EXPERT OPINION Age-related neurodegenerative disorders are fast becoming major public health problems for the world's aging populations. Several agents offer promise in the near-term, but drug development is hampered by an interrelated cycle of obstacles surrounding etiological, physiological, and biomarkers discovery. It is time for the type of government-funded, public-supported offensive on neurodegenerative disease that has been effective in other fields.
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Affiliation(s)
- H Blasco
- a Inserm U930, Equipe "neurogénétique et neurométabolomique" , Tours , France.,b Université François-Rabelais, Faculté de Médecine , Tours , France.,c Laboratoire de Biochimie et Biologie Moléculaire , CHRU de Tours , Tours , France
| | - F Patin
- a Inserm U930, Equipe "neurogénétique et neurométabolomique" , Tours , France.,b Université François-Rabelais, Faculté de Médecine , Tours , France.,c Laboratoire de Biochimie et Biologie Moléculaire , CHRU de Tours , Tours , France
| | - C R Andres
- a Inserm U930, Equipe "neurogénétique et neurométabolomique" , Tours , France.,b Université François-Rabelais, Faculté de Médecine , Tours , France.,c Laboratoire de Biochimie et Biologie Moléculaire , CHRU de Tours , Tours , France
| | - P Corcia
- a Inserm U930, Equipe "neurogénétique et neurométabolomique" , Tours , France.,b Université François-Rabelais, Faculté de Médecine , Tours , France.,d Centre SLA, Service de Neurologie , CHRU Bretonneau , Tours , France
| | - P H Gordon
- e Northern Navajo Medical Center , Neurology Unit , Shiprock , NM , USA
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Abstract
Cytokines are a heterogeneous group of glycoproteins that coordinate physiological functions. Cytokine deregulation is observed in many neurological diseases. This article reviews current research focused on human clinical trials of cytokine and anticytokine therapies in the treatment of several neurological disease including stroke, neuromuscular diseases, neuroinfectious diseases, demyelinating diseases, and neurobehavioral diseases. This research suggests that cytokine therapy applications may play an important role in offering new strategies for disease modulation and treatment. Further, this research provides insights into the causal link between cytokine deregulation and neurological diseases.
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Affiliation(s)
- Shila Azodi
- Viral Immunology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Steven Jacobson
- Viral Immunology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA.
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Ferraro D, Consonni D, Fini N, Fasano A, Del Giovane C, Mandrioli J. Amyotrophic lateral sclerosis: a comparison of two staging systems in a population-based study. Eur J Neurol 2016; 23:1426-32. [DOI: 10.1111/ene.13053] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/21/2016] [Indexed: 12/13/2022]
Affiliation(s)
- D. Ferraro
- Department of Biomedical Metabolic and Neurosciences; Nuovo Ospedale Civile S. Agostino Estense; University of Modena and Reggio Emilia; Modena
| | - D. Consonni
- Epidemiology Unit; Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico; Milan
| | - N. Fini
- Department of Biomedical Metabolic and Neurosciences; Nuovo Ospedale Civile S. Agostino Estense; University of Modena and Reggio Emilia; Modena
| | - A. Fasano
- Department of Biomedical Metabolic and Neurosciences; Nuovo Ospedale Civile S. Agostino Estense; University of Modena and Reggio Emilia; Modena
| | - C. Del Giovane
- Department of Diagnostic and Clinical Medicine and Public Health; University of Modena and Reggio Emilia; Modena Italy
| | - J. Mandrioli
- Department of Biomedical Metabolic and Neurosciences; Nuovo Ospedale Civile S. Agostino Estense; University of Modena and Reggio Emilia; Modena
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25
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Tortelli R, Copetti M, Panza F, Fontana A, Cortese R, Capozzo R, Introna A, D'Errico E, Zoccolella S, Arcuti S, Seripa D, Simone IL, Logroscino G. Time to generalization and prediction of survival in patients with amyotrophic lateral sclerosis: a retrospective observational study. Eur J Neurol 2016; 23:1117-25. [PMID: 27016147 DOI: 10.1111/ene.12994] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 02/02/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE A strong association between time to generalization (TTG), considered as the time of spreading of the clinical signs from spinal or bulbar localization to both, and survival was recently identified in patients with amyotrophic lateral sclerosis (ALS). Thus, TTG may be used as an early to intermediate end-point in survival studies. The aim of the present study was to test TTG as a predictor of survival in ALS. METHODS This was an observational retrospective study of ALS patients from a tertiary referral centre over a 5-year follow-up period. RESULTS In 212 ALS patients, TTG was associated with time to death/tracheostomy [R 0.62, 95% confidence interval (CI) 0.53-0.70; P < 0.001]. In a time-to-event analysis, longer TTG resulted in lower risk to reach a composite outcome (death or tracheostomy) both in univariate [hazard ratio (HR) 0.98, 95% CI 0.97-0.99] and multivariate Cox analyses (HR 0.98, 95% CI 0.96-0.99). TTG predicted death/tracheostomy at 4 years (C-statistic 0.58; 95% CI 0.53-0.63) and at 5 years (C-statistic 0.58; 95% CI 0.53-0.62). CONCLUSIONS Based on the present results from a large clinical cohort, TTG may be used as a new early to intermediate end-point to describe the ALS natural history. TTG may be potentially useful as a new primary outcome measure for clinical trials.
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Affiliation(s)
- R Tortelli
- Unit of Neurodegenerative Diseases, Department of Clinical Research in Neurology, University of Bari 'Aldo Moro', Tricase, Lecce, Italy
| | - M Copetti
- Unit of Biostatistics, IRCCS 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - F Panza
- Unit of Neurodegenerative Diseases, Department of Clinical Research in Neurology, University of Bari 'Aldo Moro', Tricase, Lecce, Italy.,Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy.,Geriatric Unit and Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - A Fontana
- Unit of Biostatistics, IRCCS 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - R Cortese
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
| | - R Capozzo
- Unit of Neurodegenerative Diseases, Department of Clinical Research in Neurology, University of Bari 'Aldo Moro', Tricase, Lecce, Italy
| | - A Introna
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
| | - E D'Errico
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
| | - S Zoccolella
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
| | - S Arcuti
- Unit of Neurodegenerative Diseases, Department of Clinical Research in Neurology, University of Bari 'Aldo Moro', Tricase, Lecce, Italy
| | - D Seripa
- Geriatric Unit and Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - I L Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
| | - G Logroscino
- Unit of Neurodegenerative Diseases, Department of Clinical Research in Neurology, University of Bari 'Aldo Moro', Tricase, Lecce, Italy.,Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
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Chen KS, Sakowski SA, Feldman EL. Intraspinal stem cell transplantation for amyotrophic lateral sclerosis. Ann Neurol 2016; 79:342-53. [PMID: 26696091 DOI: 10.1002/ana.24584] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disorder in which the loss of upper and lower motor neurons produces progressive weakness and eventually death. In the decades since the approval of riluzole, the only US Food and Drug Administration-approved medication to moderately slow progression of ALS, no new therapeutics have arisen to alter the course of the disease. This is partly due to our incomplete understanding of the complex pathogenesis of motor neuron degeneration. Stem cells have emerged as an attractive option in treating ALS, because they come armed with equally complex cellular machinery and may modulate the local microenvironment in many ways to rescue diseased motor neurons. Various stem cell types are being evaluated in preclinical and early clinical applications; here, we review the preclinical strategies and advances supporting the recent clinical translation of neural progenitor cell therapy for ALS. Specifically, we focus on the use of spinal cord neural progenitor cells and the pipeline starting from preclinical studies to the designs of phase I and IIa clinical trials involving direct intraspinal transplantation in humans.
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Affiliation(s)
- Kevin S Chen
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Stacey A Sakowski
- A. Alfred Taubman Medical Research Institute, University of Michigan, Ann Arbor, MI
| | - Eva L Feldman
- A. Alfred Taubman Medical Research Institute and Department of Neurology, University of Michigan, Ann Arbor, MI
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27
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Tramacere I, Dalla Bella E, Chiò A, Mora G, Filippini G, Lauria G. The MITOS system predicts long-term survival in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2015; 86:1180-5. [PMID: 25886781 DOI: 10.1136/jnnp-2014-310176] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/30/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The choice of adequate proxy for long-term survival, the ultimate outcome in randomised clinical trials (RCT) assessing disease-modifying treatments for amyotrophic lateral sclerosis (ALS), is a key issue. The intrinsic limitations of the ALS Functional Rating Scale-Revised (ALSFRS-R), including non-linearity, multidimensionality and floor-effect, have emerged and its usefulness argued. The ALS Milano-Torino staging (ALS-MITOS) system was proposed as a novel tool to measure the progression of ALS and overcome these limitations. This study was performed to validate the ALS-MITOS as a 6-month proxy of survival in 200 ALS patients followed up to 18 months. METHODS Analyses were performed on data from the recombinant human erythropoietin RCT that failed to demonstrate differences between groups for both primary and secondary outcomes. The ALS-MITOS system is composed of four key domains included in the ALSFRS-R scale (walking/self-care, swallowing, communicating and breathing), each with a threshold reflecting the loss of function in the specific ALSFRS-R subscores. Sensitivity, specificity and the area under the curve of the receiver operating characteristic curves of the ALS-MITOS system stages and ALSFRS-R decline at 6 months were calculated and compared with the primary outcome (survival, tracheotomy or >23-hour non-invasive ventilation) at 12 and 18 months Predicted probabilities of the ALS-MITO system at 6 months for any event at 12 and 18 months were computed through logistic regression models. RESULTS Disease progression from baseline to 6 months as defined by the ALS-MITOS system predicted death, tracheotomy or >23-hour non-invasive ventilation at 12 months with 82% sensitivity (95% CI 71% to 93%, n=37/45) and 63% specificity (95% CI 55% to 71%, n=92/146), and at 18 months with 71% sensitivity (95% CI 61% to 82%, n=50/70) and 68% specificity (95% CI 60% to 77%, n=76/111). The analysis of ALS-MITOS and ALSFRS-R progression at 6-month follow-up showed that the best cut-off to predict survival at 12 and 18 months was 1 for the ALS-MITOS (ie, loss of at least one function) and a decline ranging from 6 to 9 points for the ALSFRS-R. CONCLUSIONS The ALS-MITOS system can reliably predict the course of ALS up to 18 months and can be considered a novel and valid outcome measure in RCTs.
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Affiliation(s)
- Irene Tramacere
- Neuroepidemiology Unit, IRCCS Foundation, "Carlo Besta" Neurological Institute, Milan, Italy
| | - Eleonora Dalla Bella
- 3rd Neurology Unit, Motor Neuron Diseases Centre, IRCCS Foundation, "Carlo Besta" Neurological Institute, Milan, Italy
| | - Adriano Chiò
- Department of Neurosciences, ALS Centre, "Rita Levi Montalcini", University of Turin and Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Turin, Italy
| | | | - Graziella Filippini
- Neuroepidemiology Unit, IRCCS Foundation, "Carlo Besta" Neurological Institute, Milan, Italy
| | - Giuseppe Lauria
- 3rd Neurology Unit, Motor Neuron Diseases Centre, IRCCS Foundation, "Carlo Besta" Neurological Institute, Milan, Italy
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