ALS Protocol GALS-001
Study Initiation date was 16 May 2013 (first Subject pre-screened0, 03 September 2013 (first Subject screened), Study completion/Termination Date (last Subject completed) was 11 April 2014.
Safety. Of 12 patients enrolled in the study, 9 reported at least one adverse event. Overall, in the GM604 treatment group, 5 of 8 patients experienced at least one treatment emergent adverse event (TEAE) and 4 of 4 patients in the placebo group experienced at least 1 TEAE. No unexpected findings were observed. Consistent with protocol-defined expected adverse reactions, the most frequently reported AEs by GM604-treated patients in the present study were falls (4 patients, 50%), puncture site pain (3 patients, 37.5%), rash (2 patients) and headache (2 patients, 25%). Of these most commonly reported TEAEs in GM604-treated patients, falls (1 patient, 25%), puncture site pain (1 patient, 25%) and headache (2 patients, 50%) were reported in placebo-treated patients.
Adverse events in the ‘general disorders and administration site conditions’ system organ class (SOC) were the most frequently experienced adverse events (7 patients and 61 total events in both the GM604 and placebo-treated groups). A serious adverse event that required inpatient hospitalization, shortness of breath 24 days after the first dose of GM604 (12 days after the last dose), was experienced by one patient in the GM604 treatment group. This patient received the full 6 doses of GM604 treatment and then left the study site and flew back to Germany. There was no additional GM604 administered to this patient during the hospital stay in Germany that could have affected the outcome of the results.
It was determined by investigators that this serious adverse event was most likely due to the natural progression of ALS and was thus unrelated to the investigational product. No deaths or withdrawals due to adverse events occurred.
There were no clinically meaningful differences noted between patients who received GM604 and those who received placebo for changes over time in clinical laboratory tests, hematology parameters, or urinalysis results. There were no clinically meaningful differences noted between patients who received GM604 and those who received placebo for changes over time in ECGs, vital signs, physical findings, neurological examination, or other observations related to safety.
Grade 1 hypersensitivity reactions were reported by one patient receiving placebo (visit 2 during week 1) and one patient receiving GM604 (visit 5 during week 2). All other patients reported an absence of hypersensitivity (Grade 0) reactions. There was no indication of QT prolongation as no patient receiving GM604 had a QT or QTcB (QT corrected using Bazett’s formula) result above 450 msec.
Biomarker findings. Previous clinical studies in patients with ALS have suggested that biomarker concentrations in plasma, serum, and CSF can be predictive of disease progression26–33. Therefore, a primary endpoint of the present study was to examine the percentage change of each biomarker between baseline and week 12.
In plasma samples, percentage change in plasma SOD1 at visit 6 (end of week 2) was lower than at baseline (p=0.0550, two sample t-test) following GM604 treatment compared with placebo which did not lower SOD1 (Table 1, Figure 1, Dataset 134 and Dataset 1335). Percentage change in plasma total tau was significantly decreased, approximately -28% below baseline (p=0.0369 95% CI, Wilcoxon Rank Sum test) at week 6 (visit 7) after active GM604 treatment compared to placebo (Table 1, Figure 3, Dataset 236 and Dataset 1437). Percentage change in slope by treatment interaction in plasma TDP-43 from baseline (visit 1) through to week 12 (visit 8) was -34% in the GM604 treated group and +6% in the placebo group (p=00078 95% CI). The p-value of 0.0078 indicates a significant difference in slopes between GM604 and placebo up to week 12 (Table 1, Figure 2, Dataset 338 and Dataset 1539).
Table 1. GALS-001 biomarker results.
For Plasma SOD1 and Plasma Total tau: 1The P-value was obtained from a two-sample t-test for the difference in the change from baseline values between placebo and GM604. 2The P-value was obtained from a Wilcoxon Rank Sum Test for the difference in the change from baseline values between placebo and GM604. For Plasma TDP-43: Results were obtained from a mixed model repeated measures analysis for the change from baseline as the response variable with explanatory variables for week and the week by treatment interaction. The y-intercept was taken out of the model and forced to be 0 as the percentage change from baseline at baseline must be 0. The unstructured covariance structure was used to model the intra-subject correlation. 3The P-value indicates the significance of the difference in slopes between GM604 and Placebo.
Target biomarkers | Biomarkers | GM604 treated patients | Placebo patients | Comments |
---|
| Plasma SOD1 | ↓Reduced significantly at week 2 (p=0.055)1 | ↑Increased | Significant reduction of SOD1 indicates it is a target of GM604 |
| CSF SOD1 | ↓Reduced | ↑Increased | SOD 1 is a target of GM604 |
Efficacy biomarkers | Plasma Total Tau | ↓Reduced significantly at week 6 (28% below baseline, p=0.0369)2 | ↑Increased | Statistically significant reduction |
Target/efficacy biomarkers | Plasma TDP-43 | ↓Reduced significantly at week 12 (34% below baseline, p=0.0078)3 | ↑Increased (6%) | Statistically significant reduction. Indicates GM6 has a neuroprotective effect and targeted and lowered TDP-43 levels |
| CSF Cystatin C | ↑Increased | ↓Reduced | Indicates GM6 has a neuroprotective effect by increasing Cystatin C |
Prognostic biomarkers | CSF pNFH | ↓Reduced | ↓Reduced, but to a lesser extent than in GM6 treated patients. | Higher pNFH is an indicator of higher disease progression rate. |
Figure 1. SOD1 protein in CSF and plasma of GM6- and placebo control-treated patients (GALS-001).
SOD1 was measured in cerebrospinal fluid (CSF) and plasma at baseline (visit 1) and following 6 doses of GM6 over 2 weeks (visit 6). In (A) and (B) estimated SOD1 levels (pg/ml) are plotted (log10-transformed scale), with each point representing a single ALS patient. Patients below the diagonal showed decreased SOD1 post-treatment. P-values (lower right) were generated from the comparison of SOD1 measurements between visits 1 and 6 (p=0.009 one-tailed paired t-test performed using log10-transformed SOD1 estimates).
Figure 2. Percentage change in slope by treatment interaction in plasma TDP-43 over time, from baseline (visit 1) through to week 12 (visit 8) (GALS-001).
The mean change in slope for plasma TDP-43 from baseline to week 12 in the GM6 treated groups was -3.513 pg/ml, which represents a decrease of 34%, while in the placebo group the mean change in slope was 0.493 pg/ml, which represents an increase of 6% from baseline. (p=0.0078, test for the significance of difference between the slopes, GM604 vs. placebo.) (To analyze disease progression, the results of the biomarker assays were analyzed using a mixed model repeated measures analysis. Commensurate with the design of the study, a mixed effects model was used to examine differences in the percentage change from baseline over time for each of the biomarkers. The unstructured covariance structure was used to model the intra-subject correlation. Since the percentage change from baseline at baseline is zero for all subjects, the y-intercept was removed from the model which will force the y-intercept to be 0. The explanatory variables that were added to the model include the week (2, 6, 12) as a numerical variable, treatment (GM604, placebo) and the treatment by week interaction. The model was run using all results through to week 6 and then again using all results through to week 12. The p-value indicates the significance of the difference in slopes between GM604 and placebo (Dataset 1539) up to week 12.
Figure 3. Percentage change in plasma total tau over time, from baseline (visit 1) through to week 6 (visit 7) (GALS-001).
The mean percentage change from baseline for plasma total tau in GM6 treated patients was -27.69%, while the mean percentage change from baseline for the placebo group was 13.23% (p = 0.0369, Wilcoxon Rank Sum Test). This tests the significance of the difference in percentage change between the GM604 treated group and the placebo group from baseline to week 6 (Dataset 1452).
We observed suggestive trends but no statistically significant changes in CSF biomarker levels (Table 1). SOD1 levels decreased at week 6 (visit 7) following treatment with GM604 but increased following placebo treatment30. Total CSF tau was decreased after end of week 2 (visit 6, final dose) of active treatment with GM604, whereas tau increased following placebo treatment26. Cystatin C was increased after end of week 2 (visit 6, final dose) and week 12 (visit 8) following treatment with GM604, and was decreased following placebo treatment27,28.
Figure 1 compares CSF and plasma SOD1 levels at baseline (visit 1) and at the end of week 2 (visit 6, final dose) in the GM604 treated and placebo group. In Figure 1A and 1B, each point represents a single ALS patient, such that patients below the diagonal exhibit decreased SOD1 at visit 6 compared to visit 1. There was a trend towards decreased SOD1 in the CSF, but it was not statistically significant (p=0.123; one-tailed t-test; Figure 1A, Dataset 134, Dataset 440). For plasma measurements, however, SOD1 abundance was significantly lower at visit 6 compared to visit 1 (p=0.009, paired one-tailed t-test; Figure 1B)
Figure 2 shows the percentage change in slope by treatment interaction of plasma TDP-43 over time, from baseline (visit 1) through to week 12 (visit 8). The mean change in slope for the GM604 treated group was -3.513 pg/ml, which represents a 34% decrease, while the mean change in slope for the placebo group was 0.493 pg/ml, which represents a 6% increase (p=0.0078 for the difference between the slopes, -34% vs 6%, GM604 vs. placebo). To analyze disease progression, the results of the biomarker assays were analyzed using a mixed model repeated measures analysis. Commensurate with the design of the study, a mixed effects model was used to examine differences in the percentage change from baseline over time for each of the biomarkers. The covariance structure was used to model the intra-subject correlation. Since the percentage change from baseline is zero for all subjects at baseline, the y-intercept was removed from the model which forces the y-intercept to be 0. The explanatory variables that were added to the model include the week (2, 6, 12) as a numerical variable, treatment (GM604, placebo) and the treatment by week interaction. The model was run using all results through to week 6 and then again using all results through to week 12 separately. The p-value indicates a significant difference in slopes between GM604 and placebo up to week 12 (Dataset 1539).
Figure 3 shows percentage change in plasma total tau over time, from baseline (visit 1) through to week 6 (visit 7). The mean percentage change from baseline for plasma total tau in GM604 treated patients was -27.69%, while the mean percentage change from baseline for the placebo group was 13.23% (p = 0.0369, -27.69% vs 13.23%, Wilcoxon Rank Sum Test. Dataset 1437).
Efficacy assessments
TUG, grip strength and HHD scores. For weeks 2, 6 and 12, no significant treatment difference was observed between placebo and GM604 treatment groups with respect to TUG, grip strength and HHD scores18,19.
ALSFRS-R. Rates of change in ALSFRS-R are usually linear for any one individual patient (without any intervention), but are highly variable among different patients, ranging from rapid (1 year) to slow (>10 years)41. Thus, to be able to measure any change in disease progression before and after treatment, ALSFRS-R was analyzed using mixed model analysis. The model allowed for differences in slopes before and after treatment in an attempt to observe disease modification. The slope for ALSFRS-R for the placebo group changed minimally before and after treatment, going from 0.037/day to -0.034/day. The slope for the GM604 group changed noticeably but not significantly before and after treatment, going from -0.046/day before treatment to -0.032/day after treatment. It appeared that the GM604 group had slowing of disease progression compared to pre-treatment (Dataset 1642). At week 12, there was no statistically significant difference in ALSFRS-R between GM604- and placebo-treated groups (Dataset 1043).
Outcomes were also compared to baseline features of placebo-treated definite ALS patients from recent clinical trials by NEALS29,30. In our GM604-treated patients, the monthly rate of decline per 30 days was -1.047 (I. The rate of decline per 30 days among historical controls was significantly greater (-1.97 per month; p = 0.0047, -1.047/mo vs -1.97/mo, mixed model, Dataset 1744), indicating improvement in GM604-treated patients compared to an independent historical control cohort.
Forced vital capacity (FVC). At week 12, the total number of placebo- and GM604- treated patients was 4 and 7, respectively (one patient was excluded from week 12 assessments, see above). There was no statistically significant difference in the change of FVC from baseline between subjects who received placebo and those who received GM604 at week 12 (Table 2, -11.5 vs -4.7, p=0.5393, two sample t-test, Dataset 1145).
Table 2. Mean baseline and week 12 FVC (% predicted) in all GALS-001 patients.
N = number of patients. 1P-values were calculated by two-sample t Test. 2The P-value was obtained from a Wilcoxon Rank Sum Test. (Dataset 11).
Time Point | Placebo | GM604 |
---|
Baseline | | |
N | 4 | 7 |
Mean FVC % Predicted | 81.3 | 91.1 |
Week 12 | 4 | 7 |
Mean FVC % Predicted | 69.8 | 86.4 |
Change from Baseline | | |
N | 4 | 7 |
Mean FVC % Predicted change | -11.5 | -4.7 |
P-values1 Two sample t Test | | 0.5393 |
P-values2 Wilcoxon Rank Sum Test | | >0.9999 |
There were two sites included in this study (Table 3). The screening visit and baseline assessment were separated by approximately 2 weeks. Intra-site variability was quite small for the placebo group at Site 001 and at both sites for the GM604 group (ranging from 0.3 to 3.0) and not statistically significant. While some variability between visits is expected, the drop of 15 points between screening visit and baseline assessment at Site 002 for the placebo group appeared very different than what was seen at the other site (Table 3).
Table 3. Mean screening and baseline FVC (% predicted) of GALS-001 patients, separated by treatment type and site.
Time Point | Placebo All | Placebo Site 001 | Placebo Site 002 | GM604 All | GM604 Site 001 | GM604 Site 002 |
---|
Screening | 87.30 | 70.50 | 104.00 | 90.40 | 89.80 | 91.00 |
Baseline | 81.30 | 73.50 | 89.00 | 89.10 | 89.50 | 88.75 |
Only at Site 001 was there a statistically significant difference between placebo and GM604 treated group when using FVC data from baseline to week 12 (Table 4, -28 vs -4.8, p=0.0268, two sample t-test ).
Table 4. Comparing change in FVC (% predicted) from baseline to week 12 at Site 001 GALS-001 patients between placebo and GM604 treated groups.
1P-values were calculated by two-sample t Test. 2The P-value was obtained from a Wilcoxon Rank Sum Test.
Time Point | Site 001 Placebo | Site 001 GM604 |
---|
Baseline | | |
N | 2 | 4 |
Mean | 73.5 | 89.5 |
Week 12 N | | |
---|
N | 2 | 4 |
Mean | 45.5 | 84.8 |
Change from Baseline N | | |
---|
N | 2 | 4 |
Mean | -28 | -4.7 |
1P-values Two- sample t Test | | 0.0268 |
2P-values Wilcoxon Rank Sum Test | | 0.1052 |
ALS Protocol GALS-C
The GALS-001 trial was under the restrictive inclusion criteria of definite ALS onset within 24 months and FVC >65%. As a follow-on study to investigate how an advanced ALS patient would respond to GM604, a single compassionate patient case study under protocol GALS-C outside of the restrictive inclusion criteria was initiated.
The patient was a 46-year old male diagnosed 10 years previously, quadriplegic for over eight years and on a ventilator. The patient received GM604 treatment in an identical dosing regimen as in GALS-001. The patient was too advanced to perform any of the clinical endpoint assessments such as ALSFRS-R, FVC etc. as in GALS-001, but personal clinical observations were recorded according to the patient’s condition.
Clinical observations revealed small but beneficial improvements from baseline to week 12. At week 2, the patient showed clearer articulation compared to the baseline assessment. At week 4, the patient's swallow volume had increased by 150%–200%. Oral fluid consumption reported by the patient was improved, measuring 250cc total without leakage. Mouth suction, as measured by water column height, increased from 5–8 cm to 10–15 cm with both 1/8 and 1/4 inch drinking straws. Speech, swallowing, and suction were used as primary metrics, based upon the rationale that the relatively short motor neurons in the tongue and lips would show improvements first.
In this advanced patient, CSF biomarkers SOD1, Cystatin C and total tau were all below the normal range at baseline. After 2 weeks of treatment with GM604 in this advance patient, all 3 biomarkers were upregulated towards their normal range (SOD1: 50–200 ng/ml; Cystatin C: 3.0–8.0 μg/ml; total tau: 100–350 pg/ml; see Table 5). In contrast, patients treated in this Phase 2A GALS-001 trial, diagnosed within 2 years of disease onset, had CSF biomarkers SOD1 and total tau at the high end of the normal range at the start of the trial, and at week 2, both of these biomarkers were downregulated towards their normal range. Cystatin C showed values that were at the low end of the normal range at the start of the trial and were up regulated towards their normal range by week 2. Table 5 represents a compilation summary of biomarker changes in patients after GM604 treatment in the GALS-001 and GALS-C trials.
Table 5. GALS-001 and GALS-C CSF biomarker results.
GALS-C = Single compassionate patient treatment; GALS-T = GALS-001 treated group, and GALS-P = GALS-001 placebo group. ↑ = upregulation, ↓ = downregulation, DM* = disease modification, DP** = disease progression.
CSF Biomarkers | SOD1 GALS-C (N=1) | SOD1 GALS -T (N=8) | SOD1 GALS-P (N=4) | Cystatin C GALS-C (N=1) | Cystatin C GALS-T (N=8) | Cystatin C GALS - P (N=4) | total Tau GALS-C (N=1) | total Tau GALS-T (N=8) | total Tau GALS -P (N=4) |
---|
Sample-ID | Con.ng/ml | Con.ng/ml | Con.ng/ml | Conc.µg/ml | Conc.µg/ml | Conc.µg/ml | Con.pg/ml | Con.pg/ml | Con.pg/ml |
healthy range - CSF
|
50–200
|
50–200
|
50–200
|
3.0–8.0
|
3.0–8.0
|
3.0–8.0
|
100–350
|
100–350
|
100–350
|
Baseline-CSF | 27.228 | 186.6 | 137.94 | 1.97 | 3.11 | 3.23 | 60.55 | 305.03 | 386.85 |
standard deviation | | 168.3 | 56.39 | | 1.35 | 0.78 | | 122.3 | 182.93 |
Visit 6 (Week 2) -CSF | 30.996 | 153.17 | 175.86 | 2.35 | 3.15 | 3.06 | 63.33 | 303.58 | 412.96 |
standard deviation | | 76.14 | 84.56 | | 1.41 | 0.76 | | 139.37 | 196.62 |
mean % Change V6-BL | 13.84% | -3.75% | 30.45% | 19.29% | 1.57% | -4.57% | 4.59% | -1.16% | 6.43% |
standard deviation | | 26.20% | 56.90% | | 8.49% | 12.10% | | 15.79% | 6.36% |
Comments |
below range, ↑=DM*
|
high end of range, ↓=DM*
| high end of range, ↑=DP** | below range, ↑=DM* | low end of range, ↑=DM* | low end of range, ↓=DP** | below range, ↑=DM* | high end of range, ↓=DM* | above range, ↑=DP** |
Dataset 1.Plasma SOD1 measurements (GALS-001).
Dataset 2.Plasma total tau measurements (GALS-001).
Dataset 3.Plasma TDP-43 measurements (GALS-001).
Dataset 4.CSF SOD1 measurements (GALS-001).
Dataset 5.CSF total tau measurements (GALS-001).
Dataset 6.CSF Cystatin C measurements (GALS-001).
Dataset 7.CSF pNFH measurements (GALS-001).
Dataset 8.Adverse events data (GALS-001).
Dataset 9.Serious adverse event data (GALS-001).
Dataset 10.ALS Functional Rating Scale – Revised (ALSFRS-R) data (GALS-001).
Dataset 11.FVC data (GALS-001).
Dataset 12.Biomarker data for GALS-C.
Dataset 13.Source table for calculating the percentage change from baseline to week 2 for plasma SOD1.
Dataset 14.Source table for calculating the percentage change from baseline to week 6 for plasma total tau.
Dataset 15.Comparison of disease progression determined by changes in plasma TDP-43.
Dataset 16.Source table for ALSFRS-R before and after treatment (GALS-001).
Dataset 17.Source table comparing ALSFRS-R data in GM604 treated patients with data from the historical control cohort46,47.
The GM604 clinical trial Phase 2A data showed favorable shifts in ALS biomarkers and improved clinical and functional measures in ALSFRS-R and FVC during the Phase 2A clinical trial as well as in an advanced ALS patient. The biomarker results in GALS-001 suggest that GM6 may modulate ALS through multiple pathways. Our findings suggest a tentative tripartate mechanism of action (MOA) by which GM6 could prolong motor neuron survival in ALS patients. GM6 is not a cocktail of different molecules. It is an endogenous multi-target embryonic stage tyrosine kinase motoneuronotrophic factor regulator. GM6 binds to the insulin receptors, IGF1 receptors, and IGF2 receptors of the human nervous system.
Our Investigator recommended that to see the efficacy effect of GM604 after only six doses in two weeks, we should choose patients with fast progression of ALS who are definite ALS patients per El Escorial Criteria (EEC) with disease onset within two years. Our Investigator queried ALS experts as to what the rate of decline is on average with sd for patients who are diagnosed already with definite ALS EEC at study entry. We used this written reply as an independent historical control in order to look at comparison for Genervon's small study. The written information provided to us from the Ceftriaxone study was that monthly changes in ALSFRS-R was -1.97 +/- 0.057 (for definite ALS patients). We have no knowledge that this written reply may be incorrect.
In our GM604-treated definite ALS patients with fast disease progression, the monthly rate
of decline was -1.047. The rate of decline per month among historical controls was significantly greater, (-1.97 per month; p = 0.0047 95% C -1.047/mo vs -1.97/mo, mixed model, Data-set 1744), indicating improvement in GM604-treated patients compared to an independent historical control cohort.
We agree that larger trials are needed to confirm these findings, although the present data are encouraging and suggest that GM604 might be an ALS drug candidate. Genervon is planning a Phase 3 ALS trial in 2017 in the US. Enrollment detail will be announced later.
Thank you.
The GM604 clinical trial Phase 2A data showed favorable shifts in ALS biomarkers and improved clinical and functional measures in ALSFRS-R and FVC during the Phase 2A clinical trial as well as in an advanced ALS patient. The biomarker results in GALS-001 suggest that GM6 may modulate ALS through multiple pathways. Our findings suggest a tentative tripartate mechanism of action (MOA) by which GM6 could prolong motor neuron survival in ALS patients. GM6 is not a cocktail of different molecules. It is an endogenous multi-target embryonic stage tyrosine kinase motoneuronotrophic factor regulator. GM6 binds to the insulin receptors, IGF1 receptors, and IGF2 receptors of the human nervous system.
Our Investigator recommended that to see the efficacy effect of GM604 after only six doses in two weeks, we should choose patients with fast progression of ALS who are definite ALS patients per El Escorial Criteria (EEC) with disease onset within two years. Our Investigator queried ALS experts as to what the rate of decline is on average with sd for patients who are diagnosed already with definite ALS EEC at study entry. We used this written reply as an independent historical control in order to look at comparison for Genervon's small study. The written information provided to us from the Ceftriaxone study was that monthly changes in ALSFRS-R was -1.97 +/- 0.057 (for definite ALS patients). We have no knowledge that this written reply may be incorrect.
In our GM604-treated definite ALS patients with fast disease progression, the monthly rate
of decline was -1.047. The rate of decline per month among historical controls was significantly greater, (-1.97 per month; p = 0.0047 95% C -1.047/mo vs -1.97/mo, mixed model, Data-set 1744), indicating improvement in GM604-treated patients compared to an independent historical control cohort.
We agree that larger trials are needed to confirm these findings, although the present data are encouraging and suggest that GM604 might be an ALS drug candidate. Genervon is planning a Phase 3 ALS trial in 2017 in the US. Enrollment detail will be announced later.
Thank you.