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Klein EG, Schroeder K, Wessels AM, Phipps A, Japha M, Schilling T, Zimmer JA. How donanemab data address the coverage with evidence development questions. Alzheimers Dement 2024; 20:3127-3140. [PMID: 38323738 PMCID: PMC11032520 DOI: 10.1002/alz.13700] [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: 10/12/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 02/08/2024]
Abstract
The Centers for Medicare & Medicaid Services (CMS) established a class-based National Coverage Determination (NCD) for monoclonal antibodies directed against amyloid for Alzheimer's disease (AD) with patient access through Coverage with Evidence Development (CED) based on three questions. This review, focused on donanemab, answers each of these CED questions with quality evidence. TRAILBLAZER-ALZ registration trials are presented with supporting literature and real-world data to answer CED questions for donanemab. TRAILBLAZER-ALZ registration trials demonstrated that donanemab significantly slowed cognitive and functional decline in amyloid-positive early symptomatic AD participants, and lowered their risk of disease progression while key safety risks occurred primarily within the first 6 months and then declined. Donanemab meaningfully improved health outcomes with a manageable safety profile in an early symptomatic AD population, representative of Medicare populations across diverse practice settings. The donanemab data provide the necessary level of evidence for CMS to open a reconsideration of their NCD. HIGHLIGHTS: Donanemab meaningfully improved outcomes in trial participants with early symptomatic Alzheimer's disease. Comorbidities in trial participants were consistent with the Medicare population. Co-medications in trial participants were consistent with the Medicare population. Risks associated with treatment tended to occur in the first 6 months. Risks of amyloid-related imaging abnormalities were managed with careful observation and magnetic resonance imaging monitoring.
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Affiliation(s)
- Eric G. Klein
- Global Medical Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Krista Schroeder
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Alette M. Wessels
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Adam Phipps
- Lilly Value and Access, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Maureen Japha
- Corporate Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Traci Schilling
- Global Medical Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Jennifer A. Zimmer
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
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Tarawneh R, Pankratz VS. The search for clarity regarding "clinically meaningful outcomes" in Alzheimer disease clinical trials: CLARITY-AD and Beyond. Alzheimers Res Ther 2024; 16:37. [PMID: 38365811 PMCID: PMC10870501 DOI: 10.1186/s13195-024-01412-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
CLARITY-AD is an 18-month, double-blinded, placebo-controlled, phase 3 trial which examined the safety and efficacy of the anti-amyloid agent, lecanemab, in mild cognitive impairment and mild dementia due to Alzheimer disease (AD). Lecanemab effectively reduced mean brain amyloid burden and was associated with statistically significant favorable effects, reflected by moderately less decline in the primary and secondary clinical outcomes, at 18 months compared to placebo. However, there is controversy within the AD community regarding the clinical significance of these results and whether they translate into clinically meaningful and tangible benefits on cognition or daily functions.We here review the primary and secondary clinical outcomes of CLARITY-AD and present our interpretation of the potential clinical meaningfulness of the group-level differences in study outcomes in the context of the 18-month study duration. We propose that the validation of stage-appropriate group-level thresholds for clinical meaningfulness of AD trial outcomes in biologically confirmed cohorts will allow objective interpretation of trial results and guide clinical decision-making. Further, in accordance with FDA guidance which emphasizes patient-focused drug development, the contextualization of AD clinical trial outcomes can be facilitated by supplementary individual-level data analyses which measure the risk of disease progression or summarize intraindividual change, using prespecified thresholds of clinically meaningful change, in each of the study groups over the trial period. The concepts of "time-saved" and "time-based" slowing in disease progression can be used to communicate clinical outcomes associated with emerging disease-modifying AD therapies to various stakeholders. We also describe several factors that need to be considered when evaluating outcomes of emerging AD therapies, including disease stage, the neuropathologic complexity of AD, time-based effects of disease-modifying therapies, and the possible influence of individual factors on treatment response and/or risk for adverse events. The consideration of these factors in the design and reporting of future trials of emerging AD therapies will guide clinicians regarding their appropriateness for use in various patient populations.Finally, we emphasize that data from clinical cohorts with longer durations of treatment and follow-up, including extension studies and patient registries, is needed to evaluate the long-term safety and efficacy of lecanemab in early symptomatic AD.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology and Center for Memory and Aging, University of New Mexico, Albuquerque, NM, USA.
| | - Vernon S Pankratz
- Department of Internal Medicine, Division of Epidemiology, Biostatistics, and Preventive Medicine, University of New Mexico, Albuquerque, NM, USA
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Dantas JM, Mutarelli A, Navalha DDP, Dagostin CS, Romeiro PHCL, Felix N, Nogueira A, Batista S, Teixeira L, Caramelli P. Efficacy of anti-amyloid-ß monoclonal antibody therapy in early Alzheimer's disease: a systematic review and meta-analysis. Neurol Sci 2023:10.1007/s10072-023-07194-w. [PMID: 37978096 DOI: 10.1007/s10072-023-07194-w] [Citation(s) in RCA: 1] [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: 09/22/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Studies targeting amyloid-ß in patients with Alzheimer's disease (AD) have conflicting results and early initiation of therapy may yield better outcomes. METHODS We systematically searched PubMed, Embase, Cochrane Library, and Clinicaltrials.gov for randomized trials comparing monoclonal antibodies (mAbs) with placebo in MCI or mild dementia due to AD. RESULTS Nineteen studies comprising 15,275 patients were included. In patients with early AD, mAbs reduced the rate of decline, in both the Clinical Dementia Rating Scale, the sum of boxes (CDR-SB; MD -0.30; 95% CI -0.42,-0.19; p < 0.01), and the Alzheimer's Disease Assessment Scale, cognitive subscore (ADAS-cog; SMD -0.80; 95% CI -10.25,-0.35; p < 0.01). The results were similar between clinical stages for CDR-SB (MCI, MD -0.19; 95% CI -0.35,-0.03; p = 0.02; mild dementia, MD -0.45; 95% CI -0.65,-0.25; p < 0.01; subgroup differences, p = 0.13), as well as for ADAS-Cog (MCI, SMD -0.83; 95% CI -1.49,-0.17; p = 0.01; mild dementia, SMD -0.69; 95% CI -1.32 to -0.05; p = 0.03; subgroup differences, p = 0.47). The risk of amyloid-related imaging abnormalities (ARIA) was significantly higher in patients taking mAbs, including ARIA-edema (RR 7.7; 95% CI 4.60 to 13.00; p < 0.01), ARIA-hemorrhage (RR 1.8; 95% CI 1.22 to 2.59; p < 0.01), and symptomatic or serious ARIA (RR 14.1; 95% CI 7.30 to 27.14; p < 0.01). CONCLUSION Anti-amyloid-ß mAbs attenuate cognitive and functional decline compared with placebo in early AD; whether the magnitude of this effect is clinically important remains uncertain, especially relative to the safety profile of these medications. Starting immunotherapy in patients with MCI was not significantly different than starting in the mild dementia stage. PROSPERO REGISTRY CRD42023430698.
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Affiliation(s)
- Julyana M Dantas
- Universidade Federal do Rio Grande do Norte, Av. Nilo Peçanha, 620 - Petrópolis, Natal, RN, 59012-300, Brazil.
| | | | | | | | | | - Nicole Felix
- Universidade Federal de Campina Grande, Campina Grande, Brazil
| | - Alleh Nogueira
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | - Sávio Batista
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Paulo Caramelli
- Behavioral and Cognitive Neurology Unit, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Salemme S, Ancidoni A, Locuratolo N, Piscopo P, Lacorte E, Canevelli M, Vanacore N. Advances in amyloid-targeting monoclonal antibodies for Alzheimer's disease: clinical and public health issues. Expert Rev Neurother 2023; 23:1113-1129. [PMID: 37975226 DOI: 10.1080/14737175.2023.2284305] [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: 08/31/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Alzheimer's disease (AD) is a major global public health challenge. To date, no treatments have been shown to stop the underlying pathological processes. The cerebral accumulation of amyloid-beta (Ab) is still considered as the primum movens of AD and disease-modifying treatments targeting Ab are reaching - or have already reached - clinical practice. AREAS COVERED The authors explore the main advancements from Aβ-targeting monoclonal antibodies (mAbs) for the treatment of AD. From a public health perspective, they address ethically relevant issues such as the benevolence and non-maleficence principles. They report on the potential biological and clinical benefits of these drugs, discussing minimal clinically important differences (MCID) and other relevant outcomes. They examine the short- and long-term effects of amyloid-related imaging abnormalities (ARIA), and explore the differences between eligibility criteria in clinical trials, appropriate use recommendations, and prescribing information content. In doing so, they contextualize the discussion on the disagreements among different regulatory authorities. EXPERT OPINION Although anti-β-amyloid monoclonal antibodies may be effective in selected scenarios, non-negligible knowledge gaps and implementation limits persist. Overcoming these gaps can no longer be postponed if we are to ensure the principles of Quality of Care for patients with cognitive impairment who would be eligible for this class of drugs.
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Affiliation(s)
- Simone Salemme
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio Ancidoni
- National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
| | - Nicoletta Locuratolo
- National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
| | - Paola Piscopo
- Department of Neuroscience, Italian National Institute of Health, Rome, Italy
| | - Eleonora Lacorte
- National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
| | - Marco Canevelli
- National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
- Department of Human Neuroscience, "Sapienza" University, Rome, Italy
| | - Nicola Vanacore
- National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
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Melchiorri D, Merlo S, Micallef B, Borg JJ, Dráfi F. Alzheimer's disease and neuroinflammation: will new drugs in clinical trials pave the way to a multi-target therapy? Front Pharmacol 2023; 14:1196413. [PMID: 37332353 PMCID: PMC10272781 DOI: 10.3389/fphar.2023.1196413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/29/2023] [Accepted: 05/02/2023] [Indexed: 06/20/2023] Open
Abstract
Despite extensive research, no disease-modifying therapeutic option, able to prevent, cure or halt the progression of Alzheimer's disease [AD], is currently available. AD, a devastating neurodegenerative pathology leading to dementia and death, is characterized by two pathological hallmarks, the extracellular deposits of amyloid beta (Aβ) and the intraneuronal deposits of neurofibrillary tangles (NFTs) consisting of altered hyperphosphorylated tau protein. Both have been widely studied and pharmacologically targeted for many years, without significant therapeutic results. In 2022, positive data on two monoclonal antibodies targeting Aβ, donanemab and lecanemab, followed by the 2023 FDA accelerated approval of lecanemab and the publication of the final results of the phase III Clarity AD study, have strengthened the hypothesis of a causal role of Aβ in the pathogenesis of AD. However, the magnitude of the clinical effect elicited by the two drugs is limited, suggesting that additional pathological mechanisms may contribute to the disease. Cumulative studies have shown inflammation as one of the main contributors to the pathogenesis of AD, leading to the recognition of a specific role of neuroinflammation synergic with the Aβ and NFTs cascades. The present review provides an overview of the investigational drugs targeting neuroinflammation that are currently in clinical trials. Moreover, their mechanisms of action, their positioning in the pathological cascade of events that occur in the brain throughout AD disease and their potential benefit/limitation in the therapeutic strategy in AD are discussed and highlighted as well. In addition, the latest patent requests for inflammation-targeting therapeutics to be developed in AD will also be discussed.
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Affiliation(s)
- Daniela Melchiorri
- Department of Physiology and Pharmacology, Sapienza University, Rome, Italy
| | - Sara Merlo
- Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Catania, Italy
| | | | - John-Joseph Borg
- Malta Medicines Authority, San Ġwann, Malta
- School of Pharmacy, Department of Biology, University of Tor Vergata, Rome, Italy
| | - František Dráfi
- Institute of Experimental Pharmacology and Toxicology, Centre of Experimental Medicine SAS Bratislava, Bratislava, Slovakia
- State Institute for Drug Control, Bratislava, Slovakia
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Petersen RC, Aisen PS, Andrews JS, Atri A, Matthews BR, Rentz DM, Siemers ER, Weber CJ, Carrillo MC. Expectations and clinical meaningfulness of randomized controlled trials. Alzheimers Dement 2023; 19:2730-2736. [PMID: 36748826 DOI: 10.1002/alz.12959] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 02/08/2023]
Abstract
Alzheimer's disease (AD) clinical trials are designed and powered to detect the impact of a therapeutic intervention, and there has been considerable discussion on what constitutes a clinically meaningful change in those receiving treatment versus placebo. The pathology of AD is complex, beginning many years before clinical symptoms are detectable, with multiple potential opportunities for therapeutic engagement. Introducing treatment strategies early in the disease and assessing meaningful change over the course of an 18-month clinical trial are critical to understanding the value to an effective intervention. With new clinical trial data expected soon on emerging therapeutics from several AD studies, the Alzheimer's Association convened a work group of experts to discuss key considerations for interpreting data from cognitive and functional measures and what is considered a clinically meaningful benefit or meaningful slowing of this fatal disease. Our expectations of outcomes from therapeutic interventions in AD may need to be modified.
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Affiliation(s)
| | - Paul S Aisen
- USC Alzheimer's Therapeutic Research Institute, San Diego, California, USA
| | | | - Alireza Atri
- Banner Sun Health Research Institute, Banner Health, Sun City, Arizona, USA
| | | | - Dorene M Rentz
- Center for Alzheimer Research and Treatment, Brigham and Women's Hospital and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Andrews JS, Desai U, Kirson NY, Matthews BR. Response to van Dyck, O'Dell, & Mecca letter to the editor regarding Andrews et al. (2019). Alzheimers Dement (N Y) 2023; 9:e12387. [PMID: 37206624 PMCID: PMC10189864 DOI: 10.1002/trc2.12387] [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] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 05/21/2023]
Affiliation(s)
| | - Urvi Desai
- Analysis GroupInc.BostonMassachusettsUSA
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Thambisetty M, Howard R. Lecanemab trial in AD brings hope but requires greater clarity. Nat Rev Neurol 2023; 19:132-3. [PMID: 36609712 DOI: 10.1038/s41582-022-00768-w] [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: 01/07/2023]
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Dashwood M, Kuruvilla T. Lecanemab for Alzheimer's disease: new hope or another false dawn? Prog Neurol Psychiatry 2023. [DOI: 10.1002/pnp.772] [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: 02/11/2023]
Affiliation(s)
- Mark Dashwood
- Dr Dashwood is a Psychiatry Registrar and Professor Kuruvilla is a Consultant Psychiatrist, Clinical Director for Research & Visiting Professor at the School of Health & Social Care, University of Gloucestershire. Both are based at Gloucestershire Health & Care NHS Foundation Trust
| | - Tarun Kuruvilla
- Dr Dashwood is a Psychiatry Registrar and Professor Kuruvilla is a Consultant Psychiatrist, Clinical Director for Research & Visiting Professor at the School of Health & Social Care, University of Gloucestershire. Both are based at Gloucestershire Health & Care NHS Foundation Trust
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