Final Report Summary - NEUROFGL (Development of a novel FGL therapy and translational tests for regenerative treatment of neurological disorders)
Executive Summary:
Neurodegenerative disorders such as, Alzheimer’s disease (AD), Mild Cognitive Impairment (MCI), stroke, Traumatic Brain Injury (TBI) and chronic stress create a major economic burden to society and a substantial reduction in quality of life for patients and families. The development of neuroregenerative therapies is notoriously difficult and requires significant investment. NeuroFGL aimed to contribute to decrease these barriers through: (1) the clinical advancement of a promising novel regenerative therapy (FGLs) for neurological disorders, (2) hedging the clinical development by developing tests that enable early clinical assessments to be made, thereby maximising the chance that FGL and other neurogenerative therapies actually become developed to the benefit of patients and society; and (3) Selecting a target patient population with less variability and thereby easier to study – reducing and time resources needed, and increase predictability .
FGLs is a promising and novel regenerative therapy being the clinical lead development candidate selected from a group of allosteric FGF-receptor modulators (referred to as FGL) mimicking NCAM. FGL has prior to the NeuroFGL grant demonstrated positive effects in a number of in vivo models of neurodegeneration, e.g. beta-amyloid induced toxicity, global ischemia and chronic stress. The in vivo effects of FGL suggest a disease-modifying activity in several neurodegenerative disorders, such as neurogenesis.
The NeuroFGL project was successful in all the activities that were carried out during the project period, which is far better than an average development project. FGLs was in the initial toxicology tests demonstrated to be much better tolerated than anticipated when planning and applying for the NeuroFGL. The toxicity limiting dose were x20 higher than previous studies suggested. This is very positive for the longer term perspective (safer for patients) but also increases the chances to prove the mechanism (NCAM mimicking of FGF receptor) as a higher dose will increase to pick up a relevant biological activity faster compare to a situation where the dosing would have been limited by toxicity.
The lower than expected toxicity caused higher requirement of FGLs raw material for the toxicity studies and thereby some delay (it takes approx 6 months per extra batch required) and increased budget use for raw material. The final clinical trial could therefore not be completed within the project period.
The secondary outcome of NeuroFGL was also very successful. The development of a novel PET tracer ([18F]-FLT - a bromodeoxyuridin analogue) for detecting neurogenesis in vivo and EEG tests applicable for detecting a early effect of FGLs relevant for neuroplasticity was also developed in animals.
NeuroFGL did therefore successfully develop an important and potentially promising new therapy for treatment of Alzheimer’s disease into human clinical testing where it was demonstrated to be safe and well tolerated in humans. It did further develop two promising markers of biological activity; one for general detection of neurogenesis in vivo in humans ([18F]-FLT PET tracer) and one EEG based test specifying for the mode of action of FGLs detecting neuroplasticity.
Project Context and Objectives:
Neurodegenerative disorders such as, Alzheimer’s disease (AD), Mild Cognitive Impairment (MCI), stroke, Traumatic Brain Injury (TBI) and chronic stress create a major economic burden to society and a substantial reduction in quality of life for patients and families. The development of neuroregenerative therapies is notoriously difficult and requires significant investment. NeuroFGL will contribute to decrease these barriers through: (1) the clinical advancement of a promising novel regenerative therapy (FGLs) for neurological disorders, (2) hedging the clinical development by developing tests that enable early clinical assessments to be made, thereby maximising the chance that FGL and other neurogenerative therapies actually become developed to the benefit of patients and society; and (3) Selecting a target patient population with less variability and thereby easier to study – reducing and time resources needed, and increase predictability . FGLs is a promising and novel regenerative therapy being the clinical lead development candidate selected from a group of allosteric FGF-receptor modulators (referred to as FGL) mimicking NCAM. FGL has demonstrated positive effects in a number of in vivo models of neurodegeneration, e.g. beta-amyloid induced toxicity, global ischemia and chronic stress. The in vivo effects of FGL suggest a disease-modifying activity in several neurodegenerative disorders, such as neurogenesis. A phase I clinical study has demonstrated a FGL peptide to be well tolerated and safe. NeuroFGL will refine existing and develop new tests and techniques, that will at an early stage of the clinical development: (1) provide better information on the mechanisms of action (NCAM mimicking allosteric FGF receptor modulation) in man, (2) deliver translational effects seen between animal and man, (3) provide results earlier and cheaper, increasing the iteratiation and (4) select patients with conditions associated with less variability, e.g. patients with AD with a specific EEG or patients progressing to AD identified in patients with MCI. These developments will together provide a more robust basis for the development of FGLs, other drugs with a similar mechanism of action and other therapies for neurodegenerative disorders.
NeuroFGL seeks to reach clinical proof-of-concept for a promising and novel regenerative therapy (FGLs), which is the clinical lead development candidate selected from a group of allosteric FGF-receptor modulators (referred to as FGL) for the treatment of neurodegenerative disorders, such as, Alzheimer’s disease (AD), Mild Cognitive Impairment (MCI), stroke, traumatic brain injury and chronic stress. The target indications for development of FGLs are treatment of AD and MCI. To ensure achievement of these aims within the time and resources available, the different of surrogate markers demonstrating FGLs’ effect on neurogenesis will be applied. This will maximise the chances of detecting a functional effect of FGLs and achieve clinical proof-of-principle during the project and also maximise the opportunity for a larger pharmaceutical company to invest the remaining €100 million plus required to make FGLs publically available as a treatment for the benefit of society and individual patients.
The secondary outcome of NeuroFGL will be the development of a novel PET tracer ([18F]-FLT) a bromodeoxyuridin analogue) for detecting neurogenesis in vivo applicable for the development of FGLs but it will also ease the development of future neuroregenerative therapies.
This dual development of a novel therapy (FGLs) and a new marker ([18F]-FLT) will be hedged by the assessment of functional brain connectivity by electroencephalography (‘EEG’). Indeed, neural oscillations captured by EEG recordings are a fundamental mechanism for enabling coordinated activity during normal brain functioning and are therefore a crucial target for the development of neuroregenerative therapies.
Project Results:
WP1 Scientific-technical coordination and tool development
EEG: On the first place an EEG study to find correlates of icv administration of amyloid beta fragment 25-35 (Aβ25-35) in the rat was performed (an animal model of Alzheimer disease). Second goal of the present work was to describe whether any effects of FGLs will be present alone and in the Aβ25-35 model. During the EEG episodes corresponding to behavioral inactivity, the administration of Aβ25-35 induced a 20-30% increase in relative beta, high beta and gamma power (12-40 Hz) when compared to intact control animals. On the contrary SHAM animals showed the opposite with comparable magnitude of changes. Interestingly all groups, that underwent the initial surgery (icv administration) showed increased relative delta power at 1-2 Hz and decreased theta power at 4-5 Hz. EEG coherence in Aβ25-35 animals were significantly decreased in theta band when compared to both control animals and especially SHAM animals. Interestingly, FGLs tended to normalize the EEG changes in both Aβ treated animals and in the SHAM operated animals. Further, FGLs alone in intact animals induced an increase in relative power in several bands. This finding was correlated to increased plasticity in hippocampus demonstrated histological shortly after FGLs administration.
PET tracer (F18-FLT): We comprehensively assessed FGLs effects in rats in vitro and in vivo. Using a proliferation assay in an neural stem cells culture FGLs was shown to increase proliferation of neural stem cells. It was then demonstrated that NCAM drove differentiation towards a neuronal fate whereas FGLs increased the generation of oligodendrocyte precusors. The generation of astrocytes was not affected by NCAM or FGLs either. The comparison with other pharmacological agents like minocycline, ar-tumerone, or resveratrol indicated a unique effect of FGLs driving oligodendrocyte proliferation and differentiation. FGLs was then tested in naïve rats. Ex vivo, we analyzed proliferation and expansion of subventricular zone, as one of the main endogenous stem cell niche of the brain. For this, we developed a standardized method to assess the stem cell niche expansion in quantitative way by measuring the BrdU+ subventricular zone. FGLs made the subventricular zone expand significantly. These effects could be substantiated in a dose escalation study where 10 mg/kg up to doses of 250mg/kg body weight demonstrated a dose dependent effect. We have established positron emission tomography (PET) with the fluor tracer 18F-L-Thymidine (18F-FLT) to visualize stem cell proliferation in vivo (Rueger et al. 2010). PET visualized the increased uptake of the 18F tracer after FGLs treatment indicating increased proliferation of stem cells and the expansion of the stem cell niche. Still one step further, we exploited the effects of FGLs in a stroke model. FGLs did increase stem cells niche as evidenced by ex vivo methods as well as 18F-FLT PET compared to sham treated controls, and the contra lateral hemisphere. Interestingly, FGLs makes endogenous stem cell proliferate in vitro driving their differentiation towards a oligodendrocytic fate. In both naïve rat brain and in a stroke model, FGLs induces stem cell proliferation in the subventricular zone both measured by BrdU and a 18F-FLT-PET tracer visualized stem cell proliferation in vivo.
WP2 Preparation of FGLs and F18-FLT for clinical testing
C
hemistry, manufacture and controls of FGLs
FGLs is a synthetic peptide. A GMP manufacturing process has been well established. A full quality manufacturing report is available with a full description of the manufacturing process and process controls; specification limits and stability.
FGLs’ Structure
FGLs consists of two 11 amino-acid sequences connected with an iminodiacetyl linker at the N- terminals. The full structure of FGLs is shown in Figure 1. The abbreviated structure of FGLs is:
Drug substance and manufacturing process
FGLs is manufactured by solid phase peptide synthesis (SPPS) using the Fmoc (9-fluorenylmethyloxycarbonyl) strategy. The linker between the peptide and the resin is the Rink amide linker. The amino acid residues are incorporated by a succession of Fmoc deprotection and amino acid coupling cycles. After solid phase assembling of the peptide, a dimerization step is carried out with Boc-iminodiacetic acid residue using DIC/HOBt as activating reagent.
After solid phase assembling of the peptide dimer, a cleavage reaction from the resin and a concomitant side chain deprotection in one step with TFA/H2O yields directly the crude peptide with its C-terminal amide. The crude peptide is recovered by precipitation with MTBE.
Purification is performed by preparative reverse phase HPLC (high pressure liquid chromatography) in 0.1% TFA in water/acetonitrile buffer. The eluting fractions are analyzed. The pure fractions are daily pooled. Each lot of purified peptide thus obtained is tested by QC laboratory against the specification before entering in the desalting step.
Desalting is performed by preparative reverse phase HPLC in 0.1% AcOH in water/acetonitrile buffer. The eluting fractions are analyzed and concentrated. The pure fractions are daily pooled. Each lot of desalting peptide thus obtained is tested by QC laboratory against the specification before entering the final lot.
The selected pools are mixed together to form a homogeneous solution. The purified peptide with acetic acid as counter ion is clean filtered through a 0.2 micrometer membrane. The API in solution is then freeze dried before packaging.
Drug substance manufacturing campaigns conducted under NeuroFGL
During NeuroFGL four API batches have been manufactured , two more than planned for.
Batches of between 320g-1kg have been successfully manufactured in two separate facilities. The % purity FGLs is consistent with a was higher than 80%.
Stability
All historical and recent data suggest that FGLs is highly stable. Data from the first GMP batch produced under the NeuroFGL programme indicate that after 24-months of storage at -20°C±5°C no degradation is observed by HPLC and water content remains unchanged; and that 6-month stability at 25°C±2°C is 98% of the t=0 value.
Drug product presentation
Following API manufacture a drug product programme was initiated to prepare freeze-dried product in vials. Two vial presentations were manufactured – one vial containing 0.2g FGLs and one vial containing 1g FGLs. However, around 15% API was lost in the experimental apparatus during the process; and due to the lower than expected toxicity of FGLs in the toxicology programme and the resultant need for more API to complete the high dose levels; it was decided not to continue with a freeze-dried vial preparation programme up to the end of clinical Phase I.
Bioassays
Validated assay for detecting FGLs in rat plasma
Due to the high plasma levels immediately after dosing, and the need to also have a sensitive assay to measure decreasing levels of FGLs over time for toxicokinetic purposes; two rat plasma assays have been both developed and validated in Sprague-Dawley rats – a high range assay, and a low range assay. The method has been validated with regards to selectivity, sensitivity, recovery, accuracy, precision, linearity, matrix effect, carry- over, dilution and stability.
Validated assay for detecting FGLs in Non-rodent blood plasma
Due to the high plasma levels immediately after dosing, and the need to also have a sensitive assay to measure decreasing levels of FGLs over time for toxicokinetic purposes; two Non-rodent plasma assays have been both developed and validated using an LC-MS/MS method – a high range assay, and a low range assay. The method has been validated with regards to selectivity, sensitivity, recovery, accuracy, precision, linearity, matrix effect, carry-over, dilution and stability.
Validated assay for detecting FGLs in Non-rodent cerebrospinal fluid (CSF)
A validated LC-MS/MS method has been developed to determine FGLs in cerebrospinal fluid of Non-rodents. The lower and higher limits of quantitation are 50.0 and 25000 ng/mL, respectively. The method has been validated with regards to selectivity, sensitivity, recovery, accuracy, precision, linearity, matrix effect, carry-over, dilution and stability.
Cross-validation for human plasma and CSF has also been completed.
Analytical method validation
Two toxicology houses have each developed validated methods to determine the concentrations of FGLs in the reconstituted solution used for dosing. The fact that two toxicology houses have validated assays available provides risk mitigation by allowing flexibility over where additional toxicology work could be conducted without delaying the programme.
The first toxicology house developed a validated HPLC-UV method to determine the concentrations of FGLs in FGLs reconstitution solution. Validation was with respect to linearity, sensitivity, accuracy, precision, selectivity, reinjection reproducibility, blank evaluation, carryover, and concentration verification. FGLs stability in FGLs reconstitution solution was demonstrated for three freeze/thaw cycles at -20ºC, 26 hours at room temperature, and 18 days of long-term storage at 4ºC and -20ºC. FGLs stability was also demonstrated in working solution at room temperature for 16 hours, in working solution at -20ºC for 57 days, and under post preparative reinjection reproducibility conditions at 4ºC for 137 hours.
The second toxicology house has validated an analytical method for the analysis of FGLs and stability in dosing formulation. Formulations prepared up to 400mg/mL were considered to be stable over a 24 hour room temperature storage period. There was not considered to be any reduction in test article concentration after the formulations had been filtered through a 0.22µm filter. The 400mg/mL formulation formed a gel between the 0 and 4 hour time point. The physical change of the 400mg/mL formulation did not appear to affect the HPLC response of the test article. As aggregation is a potential issue with proteins and peptides, an aggregation assay was developed prior to the Neuro FGL programme since it is more sensitive than the HPLC assay (see below).
Aggregation assay
A Capillary Zone Electrophoresis (CZE) method has been established to assess the aggregation potential of FGLs in reconstituted dosing solutions. The peptide solution is injected onto a coated silica capillary. The sample migrates through the capillary under an electrical field and is detected by UV. The amount of related substances is determined as percentage of total peak area.
The assay can be used as a check for non-regulatory testing of aggregation in FGLs samples. In this regard two manufactured FGLs batches which had been used to conduct the GLP toxicology studies were assessed in the CZE assay. These were Lots MZ77229 and MZ77240. Both Lots were prepared at several concentrations and were stored as 50µL aliquots in eppendorf tubes at RT for up to 24hrs. These aliquots were then analysed by CZE. It was concluded that both FGLs Lots did not exhibit aggregation at the tested concentrations over the evaluated time course at room temperature (15-25ºC).
Toxicology studies with FGLs
An IND/CTA enabling toxicology package in two species (rat and non-rodent) has been completed in which it is concluded that FGLs is of low preclinical toxicity. The NOAEL in the 14-day Non-rodent study is 1000mg/kg/day, the highest dose tested. The No Adverse Effect Level (NOAEL) in the 14-day rat study is 750mg/kg/day; which is only due to local irritation at the site of injection and could partly be due to a high acetate content of the particular batch of FGLs tested. The effects were reversible after 14 days recovery and there were no other relevant histopathological findings. The NOAEL in the 7-day rat study was 2000mg/kg/day, the highest dose tested. These NOAELs are sufficient to provide several orders of magnitude in terms of safety over the anticipated pharmacologically active dose. The genetic toxicology and safety pharmacology GLP studies are negative, indicating the potential for a promising overall safety profile in clinical trials.
A summary of the in vitro and in vivo GLP toxicology programme follows.
In vitro metabolism and metabolic stability studies with FGLs
In order to provide a scientific rationale for the choice of the non-rodent species a small in vitro metabolism and pharmacology (DMPK) package was conducted in a side-by-side comparison of five species: CD-1 mice, Wistar Han rats, Beagle dogs, Non-rodents, and humans. The summary of the in vitro studies follows.
Metabolic stability of FGLs using cryopreserved hepatocytes (Study 399D-1202)
The objective of this study was to investigate the metabolic stability of FGLs using cryopreserved hepatocytes from CD-1 mice, Wistar Han rats, beagle dogs, Non-rodents, and humans. After incubation of FGLs at 2 µM for 240 min, the percent of initial parent remaining did not change over time, indicating that FGLs was stable in hepatocytes from all species tested. Negative control incubations showed that FGLs was stable in the incubation buffer at 37 °C for the duration of incubation. Analysis of positive control incubation samples showed that both Phase I and Phase II enzymes were active in the cryopreserved hepatocytes. It was concluded that FGLs was stable in cryopreserved hepatocytes in all five species.
Metabolic profiling and species comparison with hepatocytes (Study 399D-1203)
No metabolites were observed in CD-1 mice, Wistar Han rats, Non-rodents or humans. There were only metabolites observed in the dog. Incubations of FGLs with dog hepatocytes produced metabolites M1a, M1b, M2a, and M2b. These metabolites were most likely the products of hydrolysis plus oxidation. Specifically, most likely, loss of Ser-Lys-Ala from one N terminal, plus oxidation, resulted in M1a, which, with a further loss of Ala from another N-terminal, formed M1b; and loss of Lys-Ser-Lys-Ala from one N-terminal, plus oxidation, resulted in M2a. Loss of Ser-Lys-Ala from both N-terminals, plus oxidation, formed M2b. Thus the metabolic profile in the dog was different from that of the Non-rodents and man. In this regard the Non-rodent is likely to be a more appropriate non-rodent species to predict effects in man, rather than the dog.
Plasma protein binding and stability (Study 399D-1204)
FGLs had low protein binding in each species plasma at test conditions. The percent unbound was similar across species. Due to instability in mouse, rat, and dog plasma, the percent unbound values may be underestimated. FGLs was stable in Non-rodent plasma and human plasma with high amount remaining after 8 hours.
The findings from these in vitro DMPK studies confirmed that the Non-rodent would be more predictive of the effects in man; and hence the Non-rodent was selected as the choice for the non-rodent species in the IND/CTA enabling toxicology programme.
Repeat dose toxicology studies with FGLs
A 7-Day Repeat Dose Study in the Han Wistar Rat
A 7-day maximum tolerated dose (MTD) study followed by a 7-Day fixed dose (FD) intravenous (bolus) administration toxicity study was conducted in the Han Wistar Rat. The Han Wistar rat was selected because it was the same strain which had been used in the foundational 7-day rat study of 2008 (Enkam Study Reference CR1141). Dose levels were escalated from 25mg/kg/day to 2000 mg/kg/day; once daily for 2 or 3 days. There were no findings up to 2000mg/kg/day (the maximum dose required by regulatory guidelines in the absence of noticeable toxicity). Hence 2000mg/kg/day was carried forward to the fixed dose phase in which animals were dosed once daily for 7 days. There were no treatment-related findings at the end of the fixed dose phase and it was concluded that daily intravenous (bolus) administration of FGLs peptide was tolerated up to a maximum dose of 2000 mg/kg/day. It was noted that there appeared to be less toxicity in this study following i.v. dosing than had been observed in the foundational 7-day study of 2008 (Study CR1141) which used s.c. dosing. An additional 7-day rat study was conducted in Sprague Dawley rats; in which comparative s.c. groups were added (see below).
A 7-Day Repeat Dose Intravenous and Subcutaneous Dose range Finding Toxicity Study in Sprague-Dawley Rats (non-GLP)
The purpose of this study was to evaluate the potential toxicity of FGLs when administered once daily for 7 consecutive days to Sprague-Dawley rats via both i.v. and s.c. injection; and to evaluate the toxicokinetics (TK). In addition, the toxicity of two different presentations of FGLs was also evaluated at 750 mg/kg - a freeze-dried product in vials of either 0.2g FGLs or 1.0g FGLs per vial; and API powder).
Dose levels of 250 mg/kg and 750 mg/kg by the subcutaneous route were selected since the foundational 7-day study of 2008 (Study CR1141) had used these dose levels. It would therefore be possible to compare equivalent doses across two different strains. Taken together, the two 7-day rat studies allows an assessment of whether there are strain differences, or dose route differences; compared with the foundational 7-day study of 2008 (Study CR1141).
The results indicated that FGLs administered once daily for 7 days was well tolerated by male and female rats at 250, 750 and 2000 mg/kg i.v. and 250 and 750 mg/kg s.c. No FGLs-related changes were identified in i.v. treated groups. No apparent difference in response or toxicity was identified between the two different presentations of FGLs (i.e. as freeze-dried product of either 0.2g FGLs or 1.0g FGLs in vials; and API powder). Possible FGL-related changes, identified at the s.c. injection site, were limited to swelling (250 mg/kg s.c. and higher), hematoma (750 mg/kg s.c.) and subcutaneous hemorrhage (750 mg/kg s.c.).
The NOAEL for i.v. dosing was 2000 mg/kg, and the NOAEL for s.c. dosing was 750 mg/kg. Plasma half-life in the rat was around 45 mins.
This data suggested that there was less toxicity following i.v. dosing than s.c. dosing; and implied that much higher dose levels would be required than had originally been expected from the foundational 7-day rat study of 2008 (Enkam Study Reference CR1141).
A Maximum Tolerated Dose (MTD) followed by an 8-Day Fixed Dose Intravenous (Bolus) Administration Toxicity Study in the Non-rodent
The purpose of the study was to determine the maximum tolerated dose (MTD) of FGLs following i.v. (bolus) administration to the Non-rodent. The toxicity of repeated daily administration at the MTD for 8 days was then assessed using naïve animals. The toxicokinetic profile of FGLs was also assessed. Systemic exposure to FGLs peptide was evaluated by measuring the plasma concentrations and analyzing the resulting concentration-time data to derive toxicokinetic parameters in terms of t1/2, AUC, Cmax and Tmax.
In the maximum tolerated dose (MTD) phase of the study, the same four monkeys (2animals/sex) received i.v. bolus injections of FGLs at 25 and up to 1000 mg/kg/day on MTD study Days 1-4, 5-7, 8-10, 13-15, 16-18 and 19-21, respectively. In the Fixed Dose (FD) phase of the study, four naïve animals received daily i.v. injections of FGLs at 1000 mg/kg/day for 8 days.
During the MTD phase, blood samples were collected for toxicokinetics immediately after dosing (IAD) and at 0.25 0.5 1, 2, 4, and 8 hours post-dose on Day 1 of the first dose escalation (MTD Days 1, 5, 8, 13, 16 and 19). During the FD phase, blood samples were collected IAD and at 0.25 0.5 1, 2, 4, and 8 hours post-dose on Days 1 and 7.
There were no toxicology findings in the MTD phase up to the maximum dose level of 1000mg/kg. Thus, animals were dosed once daily in the FD phase for 7 days. An additional 8th dose was administered by i.v. 1hr before necropsy, during which CSF samples were collected. There were no toxicology findings at 1000mg/kg during the FD phase. Hence, the NOAEL was considered to be 1000mg/kg/day.
A 14-Day Intravenous and Subcutaneous Toxicity Study in Sprague-Dawley Rats with A 14-Day Recovery Phase Evaluation (GLP)
The purpose of this study was to evaluate the potential toxicity of FGLs when administered once daily for 14 consecutive days to Sprague-Dawley rats via both i.v. and s.c. injection; and to evaluate the toxicokinetics (TK). The study was conducted to GLP in support of a clinical trials application. Male and female Sprague-Dawley rats were administered the control article/vehicle (Group 1) or FGLs at 150 (Group 2) or 750 (Group 3) i.v. or s.c. FGLs administration at 150 mg/kg (Group 5) once daily for 14 consecutive days. Intravenous administration of FGLs at 2000 (Group 4) mg/kg was discontinued in both sexes on Days 6, 7, 8, or 9 of the dosing phase due to local intolerance at the site of injection. The study design is shown in Table 4.
The results showed that up to 750 mg/kg/day of once daily i.v. FGLs administration for 14 consecutive days was tolerated by male and female Sprague-Dawley rats. It was concluded that the systemic NOAEL is 750mg/kg/day and that the NOAEL for local tolerance was 150mg/kg/day.
A 15-Day Repeat Dose Study by Intravenous or Subcutaneous Bolus Injection to Non-rodents followed by a 2-Week Treatment-free Period
The objective of the study was to determine the toxicity of FGLs following intravenous/subcutaneous bolus administration to the Non-rodent for 2 weeks and to assess the reversibility of effects observed during a 2 week recovery phase. The study was conducted to GLP in support of a clinical trial application. The i.v. route of administration was chosen because it is the intended human route of administration in the first-in-man clinical trial. One s.c. group was also included to assess how pharmacokinetic exposure compared between the two dose routes; as a preliminary assessment of exploring potential alternative dose routes for long-term clinical development.
Following the in-life phase (main study and recovery phase), all study animals underwent complete necropsy. Assessment of toxicity was based on clinical observations, body weights, urine analysis, physical examinations, ophthalmoscopy, electrocardiography, blood pressure, hematology, and clinical pathology evaluations. Complete necropsy was performed on all animals with recording of macroscopic findings, organ weights and microscopic observations.
Furthermore, exposure of FGLs in the CSF was evaluated by taking CSF samples at necropsy 1 hour after the 15th dose on the morning of the necropsy.
The results of the study are summarized as follows: 1) There were no mortalities or findings regarding clinical observations, body weights, ophthalmoscopy, urine analysis, or organ weights, that could be attributed to treatment with FGLs peptide. 2) There was neither electrocardiographic evidence of cardiotoxicity nor arrhythmogenesis observed during the dosing period. 3) No test item-related effects on blood pressure measurements could be observed.
In conclusion and based on the present data, treatment with FGLs at dose levels of 0, 50, 250, and 1000mg/kg/day administered intravenously once daily for 15 days was very well tolerated and did not reveal any treatment related findings. Thus, the no observed adverse effect level (NOAEL) is considered to be the high dose of 1000 mg/kg.
Safety pharmacology GLP studies with FGLs
There are no toxicity concerns from the safety pharmacology studies. In the telemetry study dose levels up to 1000 mg/kg i.v. were well tolerated and elicited no adverse effects on the cardiovascular system (heart rate, PR, QT QRS interval; left ventricular pressure, systemic blood pressure). Therefore, the NOAEL was 1000 mg/kg.
In the rat Irwin study, intravenous administration of FGLs at dose levels of 100, 500 or 1000 mg/kg produced no behavioural, physiological or body temperature changes.
Using Whole Body Plethysmography intravenous administration of a single dose of FGLs at doses of 100, 500 and 1000 mg/kg had no effect on respiratory parameters in the rat.
In a study analysing the hERG channel it was predicted that the FGLs has a very low potential for causing QT-prolongation.
Genetic toxicology GLP studies with FGLs
The genetic toxicology studies are all negative:
In the Ames mutagenicity test there is no evidence of mutagenicity when tested up to 5000 µg/plate in the absence and presence of metabolic activation.
FGLs did not induce chromosome aberrations in cultured human peripheral blood lymphocytes when tested to 500 μg/mL, the recommended maximum concentration for testing pharmaceuticals in in vitro chromosome aberration studies according to current regulatory guidelines, in both the absence and presence of an Aroclor-induced rat liver metabolic activation system.
FGLs peptide did not induce micronuclei in the polychromatic erythrocytes of the bone marrow of male rats treated up to 2000 mg/kg/day (the recommended maximum dose level for in vivo cytogenetic assays according to current regulatory guidelines).
In vivo Pharmacokinetic Studies with FGLs
Pharmacokinetic Studies with FGLs in the Rat
PK parameters were evaluated in a 7-day repeat dose study in the Sprague-Dawley rat, in which FGLs was administered at dose levels of 250, 750 and 2000 mg/kg/day intravenously (i.v.); and 250 and 750 mg/kg/day subcutaneously (s.c.).
There were no PK gender differences over 7 days which is why the data of both sexes are combined.
There was no accumulation following repeat dosing. Rats exhibited increased exposure to FGLs with linear increases in dose over the 7-day dosing period, and the increases in AUClast following both i.v. and s.c. dosing were approximately dose-proportional or slightly less than dose proportional. The mean apparent s.c. bioavailability values in males and females were approximately 100% at 250 and 750 mg/kg/day.
Pharmacokinetic Studies with FGLs in the Non-rodent
FGLs was administered i.v. to Non-rodents in an 8-day range finding study; which consisted of an maximum tolerated dose (MTD) phase and a fixed dose (FD) phase. In the MTD phase of the study, the same four monkeys (2/sex) received i.v. bolus injections of FGLs peptide at 25, 50, 100, 250, 500 and 1000 mg/kg/day on MTD study Days 1-4, 5-7, 8-10, 13-15, 16-18 and 19-21, respectively. In the FD phase of the study, four naïve monkeys (2/sex) received daily i.v. injections of FGLs peptide at 1000 mg/kg/day for 8 days.
Overall, there were no significant gender-related differences in the toxicokinetics of FGLs. Maximum FGLs concentrations were achieved immediately after dosing (IAD) in all animals.
FGLs detected in CSF after systemic administration to Non-rodents
CSF exposure levels are very encouraging. CSF samples were taken from the three toxicology studies conducted in Non-rodents in order to measure exposure of FGLs. The overall conclusion is that very good levels of FGLs are achieved in the CSF following i.v. and s.c. dosing. CSF exposure appears to be proportional to the dose administered within the dose interval tested in the toxicity studies. The uptake of FGLs into the CSF is quick (hours) and remains present after 24h.
The studies in which CSF samples were taken were (i) the 8-Day MTD and FD study, in which CSF samples were collected at necropsy 1 day after the 1000mg/kg dose from MTD animals; and at necropsy 1hr after the 8th dose at 1000mg/kg for the FD animals; (ii) the 15-Ray Repeat Dose Toxicity Study, in which CSF samples were collected at necropsy 1hr after the 15th dose; and (iii) the telemetry study; where CSF samples were taken once week after the telemetry study had completed; but where the animals received one additional dose of 1000mg/kg and CSF samples taken by CSF samples at 30mins, 1hr, 2hr and 4hrs post-dose alongside time matched PK samples. Note, that because the aim of the Repeat Dose studies was to assess toxicity to aid dose level selection, this main aim was not jeopardized by introducing a CSF spinal tap procedure into the routine design; especially since the 15-Day Repeat Dose Study was conducted to GLP in support of dose level selection for the Phase I/II trial.
For the telemetry study CSF samples were all taken from under propofol sedation, and the lumbar area was punctured (usually between L3 to 5). For the 8-day and 15-Day repeat dose studies CSF samples were taken from the cervical end (cisterna magna), at the base of the skull; from the cervical area on animals which had received the pentobarbital dose at necropsy.
The CSF exposure data are very encouraging.
18f-FLT PET
The preclinical results of workpackage 1 made us reshape this part of the project. In vitro studies revealed new data on FGLs effects on stem cell proliferation. FGLs drives differentiation towards the oligodendrocyte lineage more than neurogenesis. The spatial expansion of the stem cell niche reflects the stem cell proliferation and is a surrogate for FGLs effetcts in vivo. The PET tracer 18F-FLT has been shown to visualize this surrogate in vivo. In vivo and ex vivo experiments evidenced most pronounced FGLs effects in acute CNS pathologies like stroke. However, it came into focus that proliferative activity of activated microglia results in 18F FLT accumulation as well, and, in addition, effects of the breakdown of the blood brain barrier (bbb) to FLT accumulation have to be eliminated by complex arithmetric algorithms. In the preclinical setting we further moved on from acute to chronic CNS pathologies. In chronic phase after stroke stem cells proliferation is minor or absent and FGLs effects are much attenuated. By contrast neuroinflammation with microglia proliferation and tissue remodeling (bbb damage) is still going on. Therefore we felt that the relative preponderance of stem cell versus microglia proliferation in the chronic stroke situation, even more in the AD situation, discourages a translational study in those chronic conditions.
To overcome the issue of interfering microglia proliferative activity we figured out a double tracer PET study employing PK11195, a carbon 11 (11C) tagged tracer that accumulated in proliferating and activated microglia. Given the short half life of the 11C tagged tracer (12min) it is feasible to inject the 11C tracer first, detect PK11195 accumulation to reveal sites of microglia proliferation, and then –after the decine of 11C – inject 18F tagged FLT to reveal sites of proliferative acitivity. Doing this in the same session allows to precisely co-register both signals. Areas of FLT accumulation without accumulation of PK1195 will reveal us true stem cell proliferation in the diseased brain. Although we are constantly apply this double tracer approach in experimental animals for years no such clinical studies have been undertaken.
As a result , the new experimental design comprises an explorative ten patient cohort for a double tracer 11C-PK11195 and 18f-FLT PET study in a subacute time window after territorial stroke. We applied for study at the local ethics committee and the governmental authorities (Bundesamt für Strahlenschutz). Multiple questions and concerns of both have been answered in due course during the last 9 months, and we final go is still pending.
The CTA (clinical trial application) for FGLs was assembled and approved by regulatory authorities (DMA).
WP3 Clinical studies
The single ascending dose (SAD) study was conducted and demonstrated that FGLs was safe and well tolerated administered in single intravenous doses up to very high doses. The pharmakinitic profile was very similar to animals.
A clinical study assessing safety of a new chemical entity is a necessity before the drug (FGLs in this case) can be tested in normal subjects with other measurements than safety (e.g. detection in CSF, cognitive measurements, EEG, PET scan fMRI etc.) or in patients.
The MAD-PD (proof of concept study) could unfortunately not be strated before the data from the SAD clinical study were ready. The MAD-PD study could therefore not be completed within the project period due to the delay caused by higher requirement of FGLs raw material and that no 6 months extension was granted by EU.
WP4 Translation between Animal data and Clinical results
The definition of a uniformed data input structure was secured upfront in the project. It was so flexible that analysis could be made across the project and ensures that data are entered homogenously. The analyse data of neurogenesis, detected by a PET imaging of an analogue of bromodeoxyuridin ([18F]-FLT) in normal animals and in an animal model of stroke was completed. Unfortunately, the test was not done on humans within the project period in patients. As a consequence the translation and the back-translation could also not be completed as they required the human data.
WP5 Dissemination and Exploitation
All the research orientated work (WP1) has been published in scientific journals. The development work (WP2 and 3) are disseminate in a non-confidential way to selected target groups in order to fund the project further phase II and II development until FGLs become available to patients with Alzheimer’s disease.
The methodology used for commercial evaluation combined secondary analysis (desk research) with primary research involving interviews with up to 20 Key Opinion Leaders (KOLs) in each therapy area across the US and Europe. The work was conducted by Globe Life Sciences Ltd.
Optional clinical indications
Improvement in cognition is essential in many neurological and psychiatric disorders, and FGLs therefore could add value in the treatment of patients within several different indications. An potential disease modifying effect in several of these indication would add a lot of potential value to the FGLs program. The optimal portfolio of clinical indications should fulfill three objectives:
• Obtain proof-of-principal for the NCAM/FGFR target in any target patient population to which FGLs is being applied
• Develop FGLs toward the indication(s) which provide high unmet medical need
• De-risk the development by selecting an indication with relatively fewer critical issues in the target product profile, e.g. the current parenteral daily administration or potential obstacles affecting any first-in-class program such as unexpected severe side effects (Acute onset of effect in depression)
The pharmacological data of FGLs and the supportive science behind the NCAM/FGFR interaction suggests that FGLs is highly relevant in treating:
• Alzheimer’s disease and other dementia indications not related to the β-amyloid hypothesis (e.g. vascular dementia)
• Cognitive improvement in depression and schizophrenia
• Disorders with poor or dysfunctional synaptogenesis, such as Fragile X and Autism
The five groups of indications have very different commercial profiles and the sensitivity to the Target Product Profile (‘TPP’) differs significantly between them. An evaluation of a number of attributes has been conducted.
At this level of analysis the ratings are subjective, but the values assigned to each criteria guide the conduct of market research and it result lead to the prioritization of ongoing development.
Market research
A market research survey was conducted with the objective of providing a commercial evaluation of FGLs in 5 priority indications.
Five indications were selected: Alzheimer’s disease and 4 others. The market attractiveness for each of the indications was assessed and held up against the TPP of FGLs leading to a prediction of the strategy and positioning scenarios (incl. sensitivity of the TPP), identification and evaluation of key risks and commercialization issues to be explored.
Conclusion
The conclusion is that all of the indications appear to represent attractive target markets from a commercial perspective, given their unmet needs and potential. However, the risks are clearly different across these indications.
Enkam’s current positioning, which will have to be adjusted based on data generated in the coming years, is to focus the commercial FGLs development on Alzheimer’s disease aimed at a relevant cognitive improvement (either stopping progression or even improving it). This indication will both provide the huge upside potential and will hedge the risk in case of not succeeding in improving the delivery to either monthly depot or oral administration, or if severe unexpected side effect should occur in later clinical development.
Enkam’s focus for the earliest, cheapest and safest proof-of-concept for FGLs and NCAM/FGFR as a target is acute onset of effect in indication 2.
A third indication were selected as a back-up indication.
Alzheimer’s disease (AD)
Overall, KOLs were clearly interested in FGLs’ concept in the treatment of AD, having a novel and differentiated and promising mechanism’ which does not rely on β-amyloid. The KOLs showed a keen interest in FGLs even if it only offered symptomatic treatment. They were looking for at least similar efficacy as current therapies – although the subcutaneous administration and potential safety risks would raise the efficacy hurdle or limit the use of FGLs for a smaller sub-population of AD patients, but not rule out the use of FGLs.
As a disease-modifying agent, KOLs regarded a statistically significant treatment effect versus placebo as the minimum acceptable efficacy, and there appeared to be more willingness to accept the subcutaneous administration and potential safety risks compared with symptomatic treatment.
Key TPP Sensitivity
Across this research, the key ‘sensitivities’ in the TPP surrounded the mode of administration and level of side effects. The need for frequent subcutaneous administration – or the presence of severe side effects – clearly increases the level of efficacy required. The profile of these two parameters may limit – or open up – indications which could be targeted with FGLs.
Potential Impact:
3.1 Expected impacts listed in the work programme
Deterioration of brain function is a normal function of aging. Neurological disorders cause an impairment or dysfunction of the brain by an abrupt or accelerated destruction of neuronal cells and their network. Present available treatments for neurodegenerative disorders tend to focus solely on symptomatic mechanisms; where lost or damaged cells are neither repaired nor their function restored by the treatment. Patients still have to live with the disabling condition resulting from the disorder itself or often treatment limiting side-effects. As a result, organs or tissues that lack the ability to self-regenerate, such as in the CNS, have become a huge health burden to patients, families/caregivers and society as a whole. For this reason these organs/tissues that are unable to regenerate are being targeted for these neuroregenerative therapies, and this is the prime focus of NeuroFGL.
Neurodegenerative disease is a global issue; current estimates indicate 35.6 million people worldwide are living with dementia but with the world’s populations ageing, the World Health Organisation estimates that number will nearly double every 20 years, to an estimated 65.7 million in 2030, and 115.4 million in 2050.( Alzheimer’s Disease International. World Alzheimer Report 2009. London: Alzheimer’s Disease International; 2009). In 2010 the prevalence of dementia in Europe was estimated to be at 9.95 million, this figure is then anticipated to increase to 13.95 million in 2030 and 18.65 million in 2050. ( Alzheimer’s Disease International. World Alzheimer Report 2009. London: Alzheimer’s Disease International; 2009). There are 7.7 million cases of dementia diagnosed each year; poor recognition, under-diagnosis and stigma mean this figure is likely to be underestimated.
Between 50 and 70 percent of all people with dementia are suffering from Alzheimer’s disease. As the disease is believed to be one of the main causes of disabilities of the elderly, its impact is on not only the health costs, but also on economic activities in general, due to a decreasing ratio of working to retired population, and on the social activities of the patients and caregivers. Consequently, it will lead to a diminished quality of life of a large portion of the EU population. Therefore, the disease has become not only a major health issue but also a major economic and social issue.
3.1.1 Health Impacts
Please see attached figure 1
Improvements in health care in the past century have contributed to people living longer and healthier lives. The elderly are anticipated to reach 115 million by 2030 ( Commission of the European Communities (2006), The demographic future of Europe-from challenge to opportunity, COM(2006). ), or represent over 25% of Europe’s population, and these diseases will become an ever more critical issue. However this has also resulted in an increase in the number of people with non-communicable diseases, including dementia. Neurodegenerative disorders and many psychiatric disorders are the result of impaired cells leading to cell death and destruction of their network. There are over 600 known neurological disorders and conditions which affect up to one billion people worldwide, 24 million living with neurological disorder and 6.8 million people die every year due to these progressive disorders. Further development of promising neurodegenerative therapies such as FGL is therefore a key step in tackling these impacts on patients and society.
Alzheimer’s disease is a physical disease affecting the brain. During the course of the disease, protein ‘plaques’ and ‘tangles’ develop in the structure of the brain, more than likely leading to impairment and death of brain cells. People with Alzheimer’s also have a shortage of some important chemicals in their brain; these chemicals are involved with the transmission of messages within the brain. Dementia is most common in the older generation, but younger people (under 65) can get it too. Thus early symptoms of AD are often mistaken to be age-related concerns; the most common symptom being impairment of the short-term memory; having difficulty in remembering recently learned facts. As the disease progresses, further symptoms include confusion, irritability and aggression, mood swings, language breakdown, long-term memory loss and general withdrawal as the person’s senses decline. Gradually, bodily functions are lost leading to death. The mean life expectancy following diagnosis is approximately seven years with less than 3% of people living for more than fourteen years after diagnosis. None of the treatments available today for Alzheimer’s disease slows or stops the death and malfunction of neurons in the brain that cause Alzheimer’s symptoms and make the disease fatal.
Depression is a psychiatric disorder closely associated with death of neuronal cells. Consequently it has been considered logical to test FGLs in its capacity of inducing neurogenesis in the treatment of depression and it has shown both acute and chronic effect, confirming the underlying sciences findings of depression and NCAM/FGFR. Depression is a severely disabling disease, and causes a significant burden both to the individual and to society. Depression is the predominant mental health challenge among working-age people and more than 30 million European citizens will suffer from depression at some point in their life. The cognitive symptoms of depression (concentration difficulties, indecisiveness, and/or forgetfulness) cause significant impairment in work function and productivity and are present 94% of the time in an episode of depression. Depression affects quality of life more than most physical illnesses, and in some cases it even leads to suicide or suicide attempts. About 15% of patients with severe depression commit suicide, whilst 56% attempt suicide and the majority have suicidal ideas during depressive episodes. There are also well established links between physical illness and depression and vice versa. The complexity of depression is not fully understood, which contributes to misdiagnosis and inadequate care for people living with the disease. The situation is aggravated by the stigmatisation of the disease which makes many reluctant to seek help. Depression is included in the NeuroFGL as a de-risking strategy for the clinical work for AD and in itself holds the potential for an interesting additional benefit.
The long-term benefits of NeuroFGL will greatly assist the EU’s research efforts to combat neurodegenerative diseases for its citizens. The aim of the project is to prove FGLs’ effect on neurogenesis in a target patient population. This will maximise the chances of detecting a relevant proof-of-principle during the project and lead to the opportunity for a larger pharmaceutical company to make FGLs publically available as a treatment that would benefit both society and individual patients.
3.1.2 Economic Impacts
Please see attached figure 2.
The cost of dementia to the economy is twice that of cancer three times that of heart disease and four times the cost associated with stroke. (Jones, R.W. Mackell, J., Berthet, K., Knox, S., (2010) Assessing Attitudes and Behaviours Surrounding Alzheimer’s Disease in Europe: Key Findings of the Important Perspectives on Alzheimer’s Care and Treatment (Impact) Survey. The Journal of Nutrition, Health & Ageing. Vol. 14, (7).)
The costs associated with dementia increase with disease severity and double between mild and severe dementia. The total estimated worldwide costs are around £400billion (US$ 604bn) in 2010 – around 1% of the world’s gross domestic product – and £23bn in the UK. This figure includes costs attributed to informal care (unpaid care provided by family and others), direct costs of social care (provided by community care professionals, and in residential home settings) and the direct costs of medical care (the costs of treating dementia and other conditions in primary and secondary care). This cost is likely to increase as the number of people with dementia rises year on year; an estimated 85% increase in costs to 2030 has been forecast.
The graphs (Figure 3) illustrate the prevalence of Alzheimer’s disease and other dementias in Europe in 2008 (the latest published figures available), together with the total costs of the illness of which 56% were costs of informal care.
Figure 4 (attached) are for the US only, however, they illustrate a quickly escalating problem that is exactly the same elsewhere in the world including Europe. The figures point out the necessity to search for a solution to this illness, the faster the better.
Costs of illness are often sub-classified as direct medical costs, direct social care costs and indirect costs.
• Direct medical costs: refer to the medical care system, such as costs of hospital care, drugs and visits to clinics.
• Direct social care costs: arise from formal services provided outside of the medical care system; for example, community services such as home care, food supply and transport, and residential or nursing home care.
• Indirect costs: usually refer to production losses linked to the person with the illness (arising from impaired productivity while working, sick leave, early retirement, or death). The costs of informal care, arising from the unpaid inputs of family caregivers, friends and others can also be considered as indirect costs. In some European countries, AD care takes approximately 10-25% of a family’s average net annual income. In 2012, in the US, 15.4 million caregivers provided an estimated 17.5 billion hours of unpaid care, valued at more than $216 billion.
The total estimated worldwide cost of dementia was US$604 billion in 2010, about 70% of the costs occur in Western Europe and North America. (http://www.alz.co.uk/research/statistics) This statistic highlights age-related neurodegenerative disease as one of the leading medical and societal challenges faced by EU society. Alzheimer’s disease is particularly expensive to manage due to its insidious onset, its ever-increasing levels of disability and the length of time over which the condition extends itself. The average duration of this disease is between 2 and 10 years, during which patients will require social care that is a significant burden for both caregivers and for society as a whole. There is a need to strengthen the health system to deliver effective care for those living with neurological disorders such as AD. Given the high cost, the economic significance of research such as NeuroFGL is substantial.
The costs of depression were estimated at €92 billion in 2010 in the EU, with lost productivity due to absenteeism (taking time off work) and presenteeism (being present at work while ill) representing over 50% of all costs related to depression. This cost rose in 2011 to €113 billion across Europe (including the EU-27 Member States, Iceland, Norway and Switzerland). Depression is associated with longer time off work compared to other occupational health problems and also generates higher levels of disability/sickness benefit claims. Across Europe, mental health problems have been identified as a leading cause of taking early retirement or a disability pension.
Currently available drugs only relieve the symptoms of neurodegenerative disease and often only temporarily, thereby leading to the need for long-term care for patients. The development of neuroregenerative medicines, based on the very promising FGLs drug candidate can potentially provide long-term benefits to patients and help to substantially reduce the costs of healthcare and caregiving. Whilst the challenges involved in taking such a neuroregenerative medicine to market should not be underestimated, the potential economic benefits that would arise from the project, taken forward into commercialisation, could be €80- €120 billion per year from 2025, in the EU alone.
3.1.3 Employment and EU competitiveness
Ageing populations and dementia are global phenomena and NeuroFGL will help to create new jobs in Europe. NeuroFGL will also help to reduce the shortage of carers and nursing homes as a consequence of a reduced number of potential patients. The market size for AD drugs, only representing a minor and temporary effect, was in 2008 US$3.4 billion (€2.7 billion) in the US alone with Eisai/Pfizer, Aricept (Donepezil) and Forest Pharmaceuticals Namenda (Memantine) being the market leaders. See Figure 5 for the latest market analysis of current AD drugs on the market. The market will undergo a period of significant growth when the first neuroregnerative therapy becomes available as it will add significant value to patients and society.
The innovative approach in NeuroFGL provides new hope for neurodegenerative disease patients, their families and caregivers and health practitioners. The project will stimulate more attractive professional environments for scientists and help to address the ‘brain drain’. Many EU Member States are determined to secure and expand their position as an international hub for innovation, medical science and research, including Denmark and the UK. This is crucial for European incorporated pharmaceutical companies, such as H. Lundbeck, to maintain their competitive advantage and retain the best talent within Europe. Therefore the project potentially contributes to the development of a new competitive advantage, new periods of growth and new employment opportunities.
In the long-term, NeuroFGL would also help to decrease the burden related to the shortage of carers and nursing homes as a consequence of a reduced number of patients and reduced severity of the patient’s disease. Shortages of professional carers and nursing homes have been a major cause of high costs and a lack of proper care given by family members. Thus, this project can contribute to the improvement of clinical management of the elderly, which is one of the main objectives of the EU Health programme.
3.1.4 Social Impacts
Dementia is a devastating disease – not just for sufferers but for their families and friends too. And as more people live longer, it is fast becoming one of the biggest social and healthcare challenges the EU faces. Making a timely and accurate diagnosis of dementia is essential to enable people to gain access to the information, support and advice they need. The provision of care to a person with dementia can result in significant strain for those who provide most of that care; the stressors are physical, emotional and economic.
People with AD lose the ability to carry out routine daily activities including dressing, undressing, using the lavatory, travelling and handling money. As a result, many require a high level of care. This is often provided by an elderly relative, whose own health and quality of life are likely to be seriously affected by the burden of care provision. Carers show considerable psychological and physical illness compared to age-matched controls, with higher levels of anxiety and depression. A survey by the UK Alzheimer’s Society indicated that nearly 60% of carers reported suffering ill health or nervous problems as a result of direct caring. Further research has shown that up to half of caregivers become depressed. (Who cares? The state of dementia care in Europe. Alzheimer’s Europe. )
Dementia 2012, showed that the number of people who felt anxious or depressed was substantial, 77% of people surveyed said they felt anxious or depressed and 61% of people with dementia feel lonely. This can have a significant impact on the quality of life for people living with neurodegenerative disease. Factors contributing to increased loneliness among people with dementia include difficulties maintaining social relationships and reduced mobility. Around 90% of people with dementia will experience behavioural and psychological symptoms (BPSD) such as aggression, agitation or psychosis (delusions and hallucinations) at some point, which severely impact on quality of life. (Cause, cure, care and prevention. Impact of Alzheimer’s Society’s dementia research programme 1990-2012. )
The European Depression Association (http://www.multivu.com/mnr/56613-european-depression-association) reports that one in ten people surveyed in Europe have taken time off work because of depression, with an average of 36 days lost per episode of depression. This equates to more than 21,000 days of lost working time in this group of people. Despite the high rates of absenteeism due to depression, one in four of those experience depression stated they did not tell their employer about the problem. Of these, one in three said they felt it would put their job at risk in the current economic climate.
3.1.5 Policy Impacts
The implementation of NeuroFGL is likely to have a range of policy impacts. NeuroFGL responds directly to the EU Health Programme 2008-2013, geared towards promoting health, including the reduction of health inequalities, the prevention of human illnesses and reducing dangers associated with mental and physical health. In particular, the project meets the criteria for Major and Chronic (MCDs) Programme, as this project is geared towards those disorders affecting a minimum of 50 per 100,000 individuals resulting in over 85% of deaths in the EU, together with Mental Health Action. Healthy mental welfare is crucial to the growing economic and social development in Europe and NeuroFGL also responds to Employment policies by proposing new methods of treatment which will help individuals (patients and carers) to continue in their employment with reduced difficulty. Specifically the project responds to the following policies:
• COM(2009) 380/4 “Communication from the Commission to the European Parliament and the Council on a European initiative on Alzheimer’s disease and other dementias”, in particular supporting effective and efficient diagnosis, treatment and research for AD in Europe.
• In 2011, the European Parliament adopted the European Parliament resolution on a European initiative on Alzheimer’s disease and other dementias (2010/2084(INI)) – the call was to make dementia an EU health priority urging Member States to develop dedicated national plans and strategies.
• NeuroFGL will take an integrated approach by bringing together research efforts from both the public and private sector on a European scale, and will assist in the development of a European Research Area (ERA).
• Quality of Life and Management of Living Resources: NeuroFGL will contribute to the EC objective of improving the quality of life of EU citizens. It will do this by delivering applications that will combat established, emerging or re-emerging diseases in humans.
• Research and Technological Development of Activities of a Generic Nature, with activities that aim to reinforce the knowledge base in those areas of strategic but generic importance for the Life Sciences related to humans.
3.1.6 Steps needed to bring about these impacts
The technical approach of NeuroFGL is defined to reach the objective of proof of principle for a promising new drug with a neuroregenerative effect, together with the development of tests that will accelerate the development of other drugs. The development plan has been designed to maximise the success of the NeuroFGL project. Monitoring the achievement of these objectives will be scheduled prospectively. The research portfolio activities is also balanced between short term and more achievable research aims as well as long term and more promising research tasks.
One of the factors that could have an influence on the realisation of the above impacts is that all results will require regulatory approval and long-term clinical trials which will restrict their immediate application. The aim of this project is to take FGLs to the point that its development risk/commercial potential ratio will be appropriate for attracting a larger pharmaceutical company to invest the remaining >€200 million that will be required to bring FGLs to the market for the benefit of patients and society as a whole.
3.1.7 Necessity to have a European approach
The specific characteristics of Alzheimer’s disease and other dementias single them out as areas where actions taken at EU level can bring added value in supporting Member States. Much of the research to date has been led at a national level however, a greater international approach could see significant advances and more scientific breakthroughs if the EU were to collaborate more effectively and share information, research and expertise. Bringing together these different players could dramatically speed up and improve how diagnosis and therapy is approached, and how research is conducted. The different partners of this project are all world-class specialists in their domain and this European approach is the best way of achieving the project objectives.
Furthermore a European approach allows the involvement of a large number of patients with different backgrounds, living conditions and causes of illness. Clinical trials that involve such diverse patients will provide robust foundation of the research. A European approach also guarantees widespread diffusion of the result across the EU.
List of Websites:
http://www.enkam.com/content/us/neurofgl
Neurodegenerative disorders such as, Alzheimer’s disease (AD), Mild Cognitive Impairment (MCI), stroke, Traumatic Brain Injury (TBI) and chronic stress create a major economic burden to society and a substantial reduction in quality of life for patients and families. The development of neuroregenerative therapies is notoriously difficult and requires significant investment. NeuroFGL aimed to contribute to decrease these barriers through: (1) the clinical advancement of a promising novel regenerative therapy (FGLs) for neurological disorders, (2) hedging the clinical development by developing tests that enable early clinical assessments to be made, thereby maximising the chance that FGL and other neurogenerative therapies actually become developed to the benefit of patients and society; and (3) Selecting a target patient population with less variability and thereby easier to study – reducing and time resources needed, and increase predictability .
FGLs is a promising and novel regenerative therapy being the clinical lead development candidate selected from a group of allosteric FGF-receptor modulators (referred to as FGL) mimicking NCAM. FGL has prior to the NeuroFGL grant demonstrated positive effects in a number of in vivo models of neurodegeneration, e.g. beta-amyloid induced toxicity, global ischemia and chronic stress. The in vivo effects of FGL suggest a disease-modifying activity in several neurodegenerative disorders, such as neurogenesis.
The NeuroFGL project was successful in all the activities that were carried out during the project period, which is far better than an average development project. FGLs was in the initial toxicology tests demonstrated to be much better tolerated than anticipated when planning and applying for the NeuroFGL. The toxicity limiting dose were x20 higher than previous studies suggested. This is very positive for the longer term perspective (safer for patients) but also increases the chances to prove the mechanism (NCAM mimicking of FGF receptor) as a higher dose will increase to pick up a relevant biological activity faster compare to a situation where the dosing would have been limited by toxicity.
The lower than expected toxicity caused higher requirement of FGLs raw material for the toxicity studies and thereby some delay (it takes approx 6 months per extra batch required) and increased budget use for raw material. The final clinical trial could therefore not be completed within the project period.
The secondary outcome of NeuroFGL was also very successful. The development of a novel PET tracer ([18F]-FLT - a bromodeoxyuridin analogue) for detecting neurogenesis in vivo and EEG tests applicable for detecting a early effect of FGLs relevant for neuroplasticity was also developed in animals.
NeuroFGL did therefore successfully develop an important and potentially promising new therapy for treatment of Alzheimer’s disease into human clinical testing where it was demonstrated to be safe and well tolerated in humans. It did further develop two promising markers of biological activity; one for general detection of neurogenesis in vivo in humans ([18F]-FLT PET tracer) and one EEG based test specifying for the mode of action of FGLs detecting neuroplasticity.
Project Context and Objectives:
Neurodegenerative disorders such as, Alzheimer’s disease (AD), Mild Cognitive Impairment (MCI), stroke, Traumatic Brain Injury (TBI) and chronic stress create a major economic burden to society and a substantial reduction in quality of life for patients and families. The development of neuroregenerative therapies is notoriously difficult and requires significant investment. NeuroFGL will contribute to decrease these barriers through: (1) the clinical advancement of a promising novel regenerative therapy (FGLs) for neurological disorders, (2) hedging the clinical development by developing tests that enable early clinical assessments to be made, thereby maximising the chance that FGL and other neurogenerative therapies actually become developed to the benefit of patients and society; and (3) Selecting a target patient population with less variability and thereby easier to study – reducing and time resources needed, and increase predictability . FGLs is a promising and novel regenerative therapy being the clinical lead development candidate selected from a group of allosteric FGF-receptor modulators (referred to as FGL) mimicking NCAM. FGL has demonstrated positive effects in a number of in vivo models of neurodegeneration, e.g. beta-amyloid induced toxicity, global ischemia and chronic stress. The in vivo effects of FGL suggest a disease-modifying activity in several neurodegenerative disorders, such as neurogenesis. A phase I clinical study has demonstrated a FGL peptide to be well tolerated and safe. NeuroFGL will refine existing and develop new tests and techniques, that will at an early stage of the clinical development: (1) provide better information on the mechanisms of action (NCAM mimicking allosteric FGF receptor modulation) in man, (2) deliver translational effects seen between animal and man, (3) provide results earlier and cheaper, increasing the iteratiation and (4) select patients with conditions associated with less variability, e.g. patients with AD with a specific EEG or patients progressing to AD identified in patients with MCI. These developments will together provide a more robust basis for the development of FGLs, other drugs with a similar mechanism of action and other therapies for neurodegenerative disorders.
NeuroFGL seeks to reach clinical proof-of-concept for a promising and novel regenerative therapy (FGLs), which is the clinical lead development candidate selected from a group of allosteric FGF-receptor modulators (referred to as FGL) for the treatment of neurodegenerative disorders, such as, Alzheimer’s disease (AD), Mild Cognitive Impairment (MCI), stroke, traumatic brain injury and chronic stress. The target indications for development of FGLs are treatment of AD and MCI. To ensure achievement of these aims within the time and resources available, the different of surrogate markers demonstrating FGLs’ effect on neurogenesis will be applied. This will maximise the chances of detecting a functional effect of FGLs and achieve clinical proof-of-principle during the project and also maximise the opportunity for a larger pharmaceutical company to invest the remaining €100 million plus required to make FGLs publically available as a treatment for the benefit of society and individual patients.
The secondary outcome of NeuroFGL will be the development of a novel PET tracer ([18F]-FLT) a bromodeoxyuridin analogue) for detecting neurogenesis in vivo applicable for the development of FGLs but it will also ease the development of future neuroregenerative therapies.
This dual development of a novel therapy (FGLs) and a new marker ([18F]-FLT) will be hedged by the assessment of functional brain connectivity by electroencephalography (‘EEG’). Indeed, neural oscillations captured by EEG recordings are a fundamental mechanism for enabling coordinated activity during normal brain functioning and are therefore a crucial target for the development of neuroregenerative therapies.
Project Results:
WP1 Scientific-technical coordination and tool development
EEG: On the first place an EEG study to find correlates of icv administration of amyloid beta fragment 25-35 (Aβ25-35) in the rat was performed (an animal model of Alzheimer disease). Second goal of the present work was to describe whether any effects of FGLs will be present alone and in the Aβ25-35 model. During the EEG episodes corresponding to behavioral inactivity, the administration of Aβ25-35 induced a 20-30% increase in relative beta, high beta and gamma power (12-40 Hz) when compared to intact control animals. On the contrary SHAM animals showed the opposite with comparable magnitude of changes. Interestingly all groups, that underwent the initial surgery (icv administration) showed increased relative delta power at 1-2 Hz and decreased theta power at 4-5 Hz. EEG coherence in Aβ25-35 animals were significantly decreased in theta band when compared to both control animals and especially SHAM animals. Interestingly, FGLs tended to normalize the EEG changes in both Aβ treated animals and in the SHAM operated animals. Further, FGLs alone in intact animals induced an increase in relative power in several bands. This finding was correlated to increased plasticity in hippocampus demonstrated histological shortly after FGLs administration.
PET tracer (F18-FLT): We comprehensively assessed FGLs effects in rats in vitro and in vivo. Using a proliferation assay in an neural stem cells culture FGLs was shown to increase proliferation of neural stem cells. It was then demonstrated that NCAM drove differentiation towards a neuronal fate whereas FGLs increased the generation of oligodendrocyte precusors. The generation of astrocytes was not affected by NCAM or FGLs either. The comparison with other pharmacological agents like minocycline, ar-tumerone, or resveratrol indicated a unique effect of FGLs driving oligodendrocyte proliferation and differentiation. FGLs was then tested in naïve rats. Ex vivo, we analyzed proliferation and expansion of subventricular zone, as one of the main endogenous stem cell niche of the brain. For this, we developed a standardized method to assess the stem cell niche expansion in quantitative way by measuring the BrdU+ subventricular zone. FGLs made the subventricular zone expand significantly. These effects could be substantiated in a dose escalation study where 10 mg/kg up to doses of 250mg/kg body weight demonstrated a dose dependent effect. We have established positron emission tomography (PET) with the fluor tracer 18F-L-Thymidine (18F-FLT) to visualize stem cell proliferation in vivo (Rueger et al. 2010). PET visualized the increased uptake of the 18F tracer after FGLs treatment indicating increased proliferation of stem cells and the expansion of the stem cell niche. Still one step further, we exploited the effects of FGLs in a stroke model. FGLs did increase stem cells niche as evidenced by ex vivo methods as well as 18F-FLT PET compared to sham treated controls, and the contra lateral hemisphere. Interestingly, FGLs makes endogenous stem cell proliferate in vitro driving their differentiation towards a oligodendrocytic fate. In both naïve rat brain and in a stroke model, FGLs induces stem cell proliferation in the subventricular zone both measured by BrdU and a 18F-FLT-PET tracer visualized stem cell proliferation in vivo.
WP2 Preparation of FGLs and F18-FLT for clinical testing
C
hemistry, manufacture and controls of FGLs
FGLs is a synthetic peptide. A GMP manufacturing process has been well established. A full quality manufacturing report is available with a full description of the manufacturing process and process controls; specification limits and stability.
FGLs’ Structure
FGLs consists of two 11 amino-acid sequences connected with an iminodiacetyl linker at the N- terminals. The full structure of FGLs is shown in Figure 1. The abbreviated structure of FGLs is:
Drug substance and manufacturing process
FGLs is manufactured by solid phase peptide synthesis (SPPS) using the Fmoc (9-fluorenylmethyloxycarbonyl) strategy. The linker between the peptide and the resin is the Rink amide linker. The amino acid residues are incorporated by a succession of Fmoc deprotection and amino acid coupling cycles. After solid phase assembling of the peptide, a dimerization step is carried out with Boc-iminodiacetic acid residue using DIC/HOBt as activating reagent.
After solid phase assembling of the peptide dimer, a cleavage reaction from the resin and a concomitant side chain deprotection in one step with TFA/H2O yields directly the crude peptide with its C-terminal amide. The crude peptide is recovered by precipitation with MTBE.
Purification is performed by preparative reverse phase HPLC (high pressure liquid chromatography) in 0.1% TFA in water/acetonitrile buffer. The eluting fractions are analyzed. The pure fractions are daily pooled. Each lot of purified peptide thus obtained is tested by QC laboratory against the specification before entering in the desalting step.
Desalting is performed by preparative reverse phase HPLC in 0.1% AcOH in water/acetonitrile buffer. The eluting fractions are analyzed and concentrated. The pure fractions are daily pooled. Each lot of desalting peptide thus obtained is tested by QC laboratory against the specification before entering the final lot.
The selected pools are mixed together to form a homogeneous solution. The purified peptide with acetic acid as counter ion is clean filtered through a 0.2 micrometer membrane. The API in solution is then freeze dried before packaging.
Drug substance manufacturing campaigns conducted under NeuroFGL
During NeuroFGL four API batches have been manufactured , two more than planned for.
Batches of between 320g-1kg have been successfully manufactured in two separate facilities. The % purity FGLs is consistent with a was higher than 80%.
Stability
All historical and recent data suggest that FGLs is highly stable. Data from the first GMP batch produced under the NeuroFGL programme indicate that after 24-months of storage at -20°C±5°C no degradation is observed by HPLC and water content remains unchanged; and that 6-month stability at 25°C±2°C is 98% of the t=0 value.
Drug product presentation
Following API manufacture a drug product programme was initiated to prepare freeze-dried product in vials. Two vial presentations were manufactured – one vial containing 0.2g FGLs and one vial containing 1g FGLs. However, around 15% API was lost in the experimental apparatus during the process; and due to the lower than expected toxicity of FGLs in the toxicology programme and the resultant need for more API to complete the high dose levels; it was decided not to continue with a freeze-dried vial preparation programme up to the end of clinical Phase I.
Bioassays
Validated assay for detecting FGLs in rat plasma
Due to the high plasma levels immediately after dosing, and the need to also have a sensitive assay to measure decreasing levels of FGLs over time for toxicokinetic purposes; two rat plasma assays have been both developed and validated in Sprague-Dawley rats – a high range assay, and a low range assay. The method has been validated with regards to selectivity, sensitivity, recovery, accuracy, precision, linearity, matrix effect, carry- over, dilution and stability.
Validated assay for detecting FGLs in Non-rodent blood plasma
Due to the high plasma levels immediately after dosing, and the need to also have a sensitive assay to measure decreasing levels of FGLs over time for toxicokinetic purposes; two Non-rodent plasma assays have been both developed and validated using an LC-MS/MS method – a high range assay, and a low range assay. The method has been validated with regards to selectivity, sensitivity, recovery, accuracy, precision, linearity, matrix effect, carry-over, dilution and stability.
Validated assay for detecting FGLs in Non-rodent cerebrospinal fluid (CSF)
A validated LC-MS/MS method has been developed to determine FGLs in cerebrospinal fluid of Non-rodents. The lower and higher limits of quantitation are 50.0 and 25000 ng/mL, respectively. The method has been validated with regards to selectivity, sensitivity, recovery, accuracy, precision, linearity, matrix effect, carry-over, dilution and stability.
Cross-validation for human plasma and CSF has also been completed.
Analytical method validation
Two toxicology houses have each developed validated methods to determine the concentrations of FGLs in the reconstituted solution used for dosing. The fact that two toxicology houses have validated assays available provides risk mitigation by allowing flexibility over where additional toxicology work could be conducted without delaying the programme.
The first toxicology house developed a validated HPLC-UV method to determine the concentrations of FGLs in FGLs reconstitution solution. Validation was with respect to linearity, sensitivity, accuracy, precision, selectivity, reinjection reproducibility, blank evaluation, carryover, and concentration verification. FGLs stability in FGLs reconstitution solution was demonstrated for three freeze/thaw cycles at -20ºC, 26 hours at room temperature, and 18 days of long-term storage at 4ºC and -20ºC. FGLs stability was also demonstrated in working solution at room temperature for 16 hours, in working solution at -20ºC for 57 days, and under post preparative reinjection reproducibility conditions at 4ºC for 137 hours.
The second toxicology house has validated an analytical method for the analysis of FGLs and stability in dosing formulation. Formulations prepared up to 400mg/mL were considered to be stable over a 24 hour room temperature storage period. There was not considered to be any reduction in test article concentration after the formulations had been filtered through a 0.22µm filter. The 400mg/mL formulation formed a gel between the 0 and 4 hour time point. The physical change of the 400mg/mL formulation did not appear to affect the HPLC response of the test article. As aggregation is a potential issue with proteins and peptides, an aggregation assay was developed prior to the Neuro FGL programme since it is more sensitive than the HPLC assay (see below).
Aggregation assay
A Capillary Zone Electrophoresis (CZE) method has been established to assess the aggregation potential of FGLs in reconstituted dosing solutions. The peptide solution is injected onto a coated silica capillary. The sample migrates through the capillary under an electrical field and is detected by UV. The amount of related substances is determined as percentage of total peak area.
The assay can be used as a check for non-regulatory testing of aggregation in FGLs samples. In this regard two manufactured FGLs batches which had been used to conduct the GLP toxicology studies were assessed in the CZE assay. These were Lots MZ77229 and MZ77240. Both Lots were prepared at several concentrations and were stored as 50µL aliquots in eppendorf tubes at RT for up to 24hrs. These aliquots were then analysed by CZE. It was concluded that both FGLs Lots did not exhibit aggregation at the tested concentrations over the evaluated time course at room temperature (15-25ºC).
Toxicology studies with FGLs
An IND/CTA enabling toxicology package in two species (rat and non-rodent) has been completed in which it is concluded that FGLs is of low preclinical toxicity. The NOAEL in the 14-day Non-rodent study is 1000mg/kg/day, the highest dose tested. The No Adverse Effect Level (NOAEL) in the 14-day rat study is 750mg/kg/day; which is only due to local irritation at the site of injection and could partly be due to a high acetate content of the particular batch of FGLs tested. The effects were reversible after 14 days recovery and there were no other relevant histopathological findings. The NOAEL in the 7-day rat study was 2000mg/kg/day, the highest dose tested. These NOAELs are sufficient to provide several orders of magnitude in terms of safety over the anticipated pharmacologically active dose. The genetic toxicology and safety pharmacology GLP studies are negative, indicating the potential for a promising overall safety profile in clinical trials.
A summary of the in vitro and in vivo GLP toxicology programme follows.
In vitro metabolism and metabolic stability studies with FGLs
In order to provide a scientific rationale for the choice of the non-rodent species a small in vitro metabolism and pharmacology (DMPK) package was conducted in a side-by-side comparison of five species: CD-1 mice, Wistar Han rats, Beagle dogs, Non-rodents, and humans. The summary of the in vitro studies follows.
Metabolic stability of FGLs using cryopreserved hepatocytes (Study 399D-1202)
The objective of this study was to investigate the metabolic stability of FGLs using cryopreserved hepatocytes from CD-1 mice, Wistar Han rats, beagle dogs, Non-rodents, and humans. After incubation of FGLs at 2 µM for 240 min, the percent of initial parent remaining did not change over time, indicating that FGLs was stable in hepatocytes from all species tested. Negative control incubations showed that FGLs was stable in the incubation buffer at 37 °C for the duration of incubation. Analysis of positive control incubation samples showed that both Phase I and Phase II enzymes were active in the cryopreserved hepatocytes. It was concluded that FGLs was stable in cryopreserved hepatocytes in all five species.
Metabolic profiling and species comparison with hepatocytes (Study 399D-1203)
No metabolites were observed in CD-1 mice, Wistar Han rats, Non-rodents or humans. There were only metabolites observed in the dog. Incubations of FGLs with dog hepatocytes produced metabolites M1a, M1b, M2a, and M2b. These metabolites were most likely the products of hydrolysis plus oxidation. Specifically, most likely, loss of Ser-Lys-Ala from one N terminal, plus oxidation, resulted in M1a, which, with a further loss of Ala from another N-terminal, formed M1b; and loss of Lys-Ser-Lys-Ala from one N-terminal, plus oxidation, resulted in M2a. Loss of Ser-Lys-Ala from both N-terminals, plus oxidation, formed M2b. Thus the metabolic profile in the dog was different from that of the Non-rodents and man. In this regard the Non-rodent is likely to be a more appropriate non-rodent species to predict effects in man, rather than the dog.
Plasma protein binding and stability (Study 399D-1204)
FGLs had low protein binding in each species plasma at test conditions. The percent unbound was similar across species. Due to instability in mouse, rat, and dog plasma, the percent unbound values may be underestimated. FGLs was stable in Non-rodent plasma and human plasma with high amount remaining after 8 hours.
The findings from these in vitro DMPK studies confirmed that the Non-rodent would be more predictive of the effects in man; and hence the Non-rodent was selected as the choice for the non-rodent species in the IND/CTA enabling toxicology programme.
Repeat dose toxicology studies with FGLs
A 7-Day Repeat Dose Study in the Han Wistar Rat
A 7-day maximum tolerated dose (MTD) study followed by a 7-Day fixed dose (FD) intravenous (bolus) administration toxicity study was conducted in the Han Wistar Rat. The Han Wistar rat was selected because it was the same strain which had been used in the foundational 7-day rat study of 2008 (Enkam Study Reference CR1141). Dose levels were escalated from 25mg/kg/day to 2000 mg/kg/day; once daily for 2 or 3 days. There were no findings up to 2000mg/kg/day (the maximum dose required by regulatory guidelines in the absence of noticeable toxicity). Hence 2000mg/kg/day was carried forward to the fixed dose phase in which animals were dosed once daily for 7 days. There were no treatment-related findings at the end of the fixed dose phase and it was concluded that daily intravenous (bolus) administration of FGLs peptide was tolerated up to a maximum dose of 2000 mg/kg/day. It was noted that there appeared to be less toxicity in this study following i.v. dosing than had been observed in the foundational 7-day study of 2008 (Study CR1141) which used s.c. dosing. An additional 7-day rat study was conducted in Sprague Dawley rats; in which comparative s.c. groups were added (see below).
A 7-Day Repeat Dose Intravenous and Subcutaneous Dose range Finding Toxicity Study in Sprague-Dawley Rats (non-GLP)
The purpose of this study was to evaluate the potential toxicity of FGLs when administered once daily for 7 consecutive days to Sprague-Dawley rats via both i.v. and s.c. injection; and to evaluate the toxicokinetics (TK). In addition, the toxicity of two different presentations of FGLs was also evaluated at 750 mg/kg - a freeze-dried product in vials of either 0.2g FGLs or 1.0g FGLs per vial; and API powder).
Dose levels of 250 mg/kg and 750 mg/kg by the subcutaneous route were selected since the foundational 7-day study of 2008 (Study CR1141) had used these dose levels. It would therefore be possible to compare equivalent doses across two different strains. Taken together, the two 7-day rat studies allows an assessment of whether there are strain differences, or dose route differences; compared with the foundational 7-day study of 2008 (Study CR1141).
The results indicated that FGLs administered once daily for 7 days was well tolerated by male and female rats at 250, 750 and 2000 mg/kg i.v. and 250 and 750 mg/kg s.c. No FGLs-related changes were identified in i.v. treated groups. No apparent difference in response or toxicity was identified between the two different presentations of FGLs (i.e. as freeze-dried product of either 0.2g FGLs or 1.0g FGLs in vials; and API powder). Possible FGL-related changes, identified at the s.c. injection site, were limited to swelling (250 mg/kg s.c. and higher), hematoma (750 mg/kg s.c.) and subcutaneous hemorrhage (750 mg/kg s.c.).
The NOAEL for i.v. dosing was 2000 mg/kg, and the NOAEL for s.c. dosing was 750 mg/kg. Plasma half-life in the rat was around 45 mins.
This data suggested that there was less toxicity following i.v. dosing than s.c. dosing; and implied that much higher dose levels would be required than had originally been expected from the foundational 7-day rat study of 2008 (Enkam Study Reference CR1141).
A Maximum Tolerated Dose (MTD) followed by an 8-Day Fixed Dose Intravenous (Bolus) Administration Toxicity Study in the Non-rodent
The purpose of the study was to determine the maximum tolerated dose (MTD) of FGLs following i.v. (bolus) administration to the Non-rodent. The toxicity of repeated daily administration at the MTD for 8 days was then assessed using naïve animals. The toxicokinetic profile of FGLs was also assessed. Systemic exposure to FGLs peptide was evaluated by measuring the plasma concentrations and analyzing the resulting concentration-time data to derive toxicokinetic parameters in terms of t1/2, AUC, Cmax and Tmax.
In the maximum tolerated dose (MTD) phase of the study, the same four monkeys (2animals/sex) received i.v. bolus injections of FGLs at 25 and up to 1000 mg/kg/day on MTD study Days 1-4, 5-7, 8-10, 13-15, 16-18 and 19-21, respectively. In the Fixed Dose (FD) phase of the study, four naïve animals received daily i.v. injections of FGLs at 1000 mg/kg/day for 8 days.
During the MTD phase, blood samples were collected for toxicokinetics immediately after dosing (IAD) and at 0.25 0.5 1, 2, 4, and 8 hours post-dose on Day 1 of the first dose escalation (MTD Days 1, 5, 8, 13, 16 and 19). During the FD phase, blood samples were collected IAD and at 0.25 0.5 1, 2, 4, and 8 hours post-dose on Days 1 and 7.
There were no toxicology findings in the MTD phase up to the maximum dose level of 1000mg/kg. Thus, animals were dosed once daily in the FD phase for 7 days. An additional 8th dose was administered by i.v. 1hr before necropsy, during which CSF samples were collected. There were no toxicology findings at 1000mg/kg during the FD phase. Hence, the NOAEL was considered to be 1000mg/kg/day.
A 14-Day Intravenous and Subcutaneous Toxicity Study in Sprague-Dawley Rats with A 14-Day Recovery Phase Evaluation (GLP)
The purpose of this study was to evaluate the potential toxicity of FGLs when administered once daily for 14 consecutive days to Sprague-Dawley rats via both i.v. and s.c. injection; and to evaluate the toxicokinetics (TK). The study was conducted to GLP in support of a clinical trials application. Male and female Sprague-Dawley rats were administered the control article/vehicle (Group 1) or FGLs at 150 (Group 2) or 750 (Group 3) i.v. or s.c. FGLs administration at 150 mg/kg (Group 5) once daily for 14 consecutive days. Intravenous administration of FGLs at 2000 (Group 4) mg/kg was discontinued in both sexes on Days 6, 7, 8, or 9 of the dosing phase due to local intolerance at the site of injection. The study design is shown in Table 4.
The results showed that up to 750 mg/kg/day of once daily i.v. FGLs administration for 14 consecutive days was tolerated by male and female Sprague-Dawley rats. It was concluded that the systemic NOAEL is 750mg/kg/day and that the NOAEL for local tolerance was 150mg/kg/day.
A 15-Day Repeat Dose Study by Intravenous or Subcutaneous Bolus Injection to Non-rodents followed by a 2-Week Treatment-free Period
The objective of the study was to determine the toxicity of FGLs following intravenous/subcutaneous bolus administration to the Non-rodent for 2 weeks and to assess the reversibility of effects observed during a 2 week recovery phase. The study was conducted to GLP in support of a clinical trial application. The i.v. route of administration was chosen because it is the intended human route of administration in the first-in-man clinical trial. One s.c. group was also included to assess how pharmacokinetic exposure compared between the two dose routes; as a preliminary assessment of exploring potential alternative dose routes for long-term clinical development.
Following the in-life phase (main study and recovery phase), all study animals underwent complete necropsy. Assessment of toxicity was based on clinical observations, body weights, urine analysis, physical examinations, ophthalmoscopy, electrocardiography, blood pressure, hematology, and clinical pathology evaluations. Complete necropsy was performed on all animals with recording of macroscopic findings, organ weights and microscopic observations.
Furthermore, exposure of FGLs in the CSF was evaluated by taking CSF samples at necropsy 1 hour after the 15th dose on the morning of the necropsy.
The results of the study are summarized as follows: 1) There were no mortalities or findings regarding clinical observations, body weights, ophthalmoscopy, urine analysis, or organ weights, that could be attributed to treatment with FGLs peptide. 2) There was neither electrocardiographic evidence of cardiotoxicity nor arrhythmogenesis observed during the dosing period. 3) No test item-related effects on blood pressure measurements could be observed.
In conclusion and based on the present data, treatment with FGLs at dose levels of 0, 50, 250, and 1000mg/kg/day administered intravenously once daily for 15 days was very well tolerated and did not reveal any treatment related findings. Thus, the no observed adverse effect level (NOAEL) is considered to be the high dose of 1000 mg/kg.
Safety pharmacology GLP studies with FGLs
There are no toxicity concerns from the safety pharmacology studies. In the telemetry study dose levels up to 1000 mg/kg i.v. were well tolerated and elicited no adverse effects on the cardiovascular system (heart rate, PR, QT QRS interval; left ventricular pressure, systemic blood pressure). Therefore, the NOAEL was 1000 mg/kg.
In the rat Irwin study, intravenous administration of FGLs at dose levels of 100, 500 or 1000 mg/kg produced no behavioural, physiological or body temperature changes.
Using Whole Body Plethysmography intravenous administration of a single dose of FGLs at doses of 100, 500 and 1000 mg/kg had no effect on respiratory parameters in the rat.
In a study analysing the hERG channel it was predicted that the FGLs has a very low potential for causing QT-prolongation.
Genetic toxicology GLP studies with FGLs
The genetic toxicology studies are all negative:
In the Ames mutagenicity test there is no evidence of mutagenicity when tested up to 5000 µg/plate in the absence and presence of metabolic activation.
FGLs did not induce chromosome aberrations in cultured human peripheral blood lymphocytes when tested to 500 μg/mL, the recommended maximum concentration for testing pharmaceuticals in in vitro chromosome aberration studies according to current regulatory guidelines, in both the absence and presence of an Aroclor-induced rat liver metabolic activation system.
FGLs peptide did not induce micronuclei in the polychromatic erythrocytes of the bone marrow of male rats treated up to 2000 mg/kg/day (the recommended maximum dose level for in vivo cytogenetic assays according to current regulatory guidelines).
In vivo Pharmacokinetic Studies with FGLs
Pharmacokinetic Studies with FGLs in the Rat
PK parameters were evaluated in a 7-day repeat dose study in the Sprague-Dawley rat, in which FGLs was administered at dose levels of 250, 750 and 2000 mg/kg/day intravenously (i.v.); and 250 and 750 mg/kg/day subcutaneously (s.c.).
There were no PK gender differences over 7 days which is why the data of both sexes are combined.
There was no accumulation following repeat dosing. Rats exhibited increased exposure to FGLs with linear increases in dose over the 7-day dosing period, and the increases in AUClast following both i.v. and s.c. dosing were approximately dose-proportional or slightly less than dose proportional. The mean apparent s.c. bioavailability values in males and females were approximately 100% at 250 and 750 mg/kg/day.
Pharmacokinetic Studies with FGLs in the Non-rodent
FGLs was administered i.v. to Non-rodents in an 8-day range finding study; which consisted of an maximum tolerated dose (MTD) phase and a fixed dose (FD) phase. In the MTD phase of the study, the same four monkeys (2/sex) received i.v. bolus injections of FGLs peptide at 25, 50, 100, 250, 500 and 1000 mg/kg/day on MTD study Days 1-4, 5-7, 8-10, 13-15, 16-18 and 19-21, respectively. In the FD phase of the study, four naïve monkeys (2/sex) received daily i.v. injections of FGLs peptide at 1000 mg/kg/day for 8 days.
Overall, there were no significant gender-related differences in the toxicokinetics of FGLs. Maximum FGLs concentrations were achieved immediately after dosing (IAD) in all animals.
FGLs detected in CSF after systemic administration to Non-rodents
CSF exposure levels are very encouraging. CSF samples were taken from the three toxicology studies conducted in Non-rodents in order to measure exposure of FGLs. The overall conclusion is that very good levels of FGLs are achieved in the CSF following i.v. and s.c. dosing. CSF exposure appears to be proportional to the dose administered within the dose interval tested in the toxicity studies. The uptake of FGLs into the CSF is quick (hours) and remains present after 24h.
The studies in which CSF samples were taken were (i) the 8-Day MTD and FD study, in which CSF samples were collected at necropsy 1 day after the 1000mg/kg dose from MTD animals; and at necropsy 1hr after the 8th dose at 1000mg/kg for the FD animals; (ii) the 15-Ray Repeat Dose Toxicity Study, in which CSF samples were collected at necropsy 1hr after the 15th dose; and (iii) the telemetry study; where CSF samples were taken once week after the telemetry study had completed; but where the animals received one additional dose of 1000mg/kg and CSF samples taken by CSF samples at 30mins, 1hr, 2hr and 4hrs post-dose alongside time matched PK samples. Note, that because the aim of the Repeat Dose studies was to assess toxicity to aid dose level selection, this main aim was not jeopardized by introducing a CSF spinal tap procedure into the routine design; especially since the 15-Day Repeat Dose Study was conducted to GLP in support of dose level selection for the Phase I/II trial.
For the telemetry study CSF samples were all taken from under propofol sedation, and the lumbar area was punctured (usually between L3 to 5). For the 8-day and 15-Day repeat dose studies CSF samples were taken from the cervical end (cisterna magna), at the base of the skull; from the cervical area on animals which had received the pentobarbital dose at necropsy.
The CSF exposure data are very encouraging.
18f-FLT PET
The preclinical results of workpackage 1 made us reshape this part of the project. In vitro studies revealed new data on FGLs effects on stem cell proliferation. FGLs drives differentiation towards the oligodendrocyte lineage more than neurogenesis. The spatial expansion of the stem cell niche reflects the stem cell proliferation and is a surrogate for FGLs effetcts in vivo. The PET tracer 18F-FLT has been shown to visualize this surrogate in vivo. In vivo and ex vivo experiments evidenced most pronounced FGLs effects in acute CNS pathologies like stroke. However, it came into focus that proliferative activity of activated microglia results in 18F FLT accumulation as well, and, in addition, effects of the breakdown of the blood brain barrier (bbb) to FLT accumulation have to be eliminated by complex arithmetric algorithms. In the preclinical setting we further moved on from acute to chronic CNS pathologies. In chronic phase after stroke stem cells proliferation is minor or absent and FGLs effects are much attenuated. By contrast neuroinflammation with microglia proliferation and tissue remodeling (bbb damage) is still going on. Therefore we felt that the relative preponderance of stem cell versus microglia proliferation in the chronic stroke situation, even more in the AD situation, discourages a translational study in those chronic conditions.
To overcome the issue of interfering microglia proliferative activity we figured out a double tracer PET study employing PK11195, a carbon 11 (11C) tagged tracer that accumulated in proliferating and activated microglia. Given the short half life of the 11C tagged tracer (12min) it is feasible to inject the 11C tracer first, detect PK11195 accumulation to reveal sites of microglia proliferation, and then –after the decine of 11C – inject 18F tagged FLT to reveal sites of proliferative acitivity. Doing this in the same session allows to precisely co-register both signals. Areas of FLT accumulation without accumulation of PK1195 will reveal us true stem cell proliferation in the diseased brain. Although we are constantly apply this double tracer approach in experimental animals for years no such clinical studies have been undertaken.
As a result , the new experimental design comprises an explorative ten patient cohort for a double tracer 11C-PK11195 and 18f-FLT PET study in a subacute time window after territorial stroke. We applied for study at the local ethics committee and the governmental authorities (Bundesamt für Strahlenschutz). Multiple questions and concerns of both have been answered in due course during the last 9 months, and we final go is still pending.
The CTA (clinical trial application) for FGLs was assembled and approved by regulatory authorities (DMA).
WP3 Clinical studies
The single ascending dose (SAD) study was conducted and demonstrated that FGLs was safe and well tolerated administered in single intravenous doses up to very high doses. The pharmakinitic profile was very similar to animals.
A clinical study assessing safety of a new chemical entity is a necessity before the drug (FGLs in this case) can be tested in normal subjects with other measurements than safety (e.g. detection in CSF, cognitive measurements, EEG, PET scan fMRI etc.) or in patients.
The MAD-PD (proof of concept study) could unfortunately not be strated before the data from the SAD clinical study were ready. The MAD-PD study could therefore not be completed within the project period due to the delay caused by higher requirement of FGLs raw material and that no 6 months extension was granted by EU.
WP4 Translation between Animal data and Clinical results
The definition of a uniformed data input structure was secured upfront in the project. It was so flexible that analysis could be made across the project and ensures that data are entered homogenously. The analyse data of neurogenesis, detected by a PET imaging of an analogue of bromodeoxyuridin ([18F]-FLT) in normal animals and in an animal model of stroke was completed. Unfortunately, the test was not done on humans within the project period in patients. As a consequence the translation and the back-translation could also not be completed as they required the human data.
WP5 Dissemination and Exploitation
All the research orientated work (WP1) has been published in scientific journals. The development work (WP2 and 3) are disseminate in a non-confidential way to selected target groups in order to fund the project further phase II and II development until FGLs become available to patients with Alzheimer’s disease.
The methodology used for commercial evaluation combined secondary analysis (desk research) with primary research involving interviews with up to 20 Key Opinion Leaders (KOLs) in each therapy area across the US and Europe. The work was conducted by Globe Life Sciences Ltd.
Optional clinical indications
Improvement in cognition is essential in many neurological and psychiatric disorders, and FGLs therefore could add value in the treatment of patients within several different indications. An potential disease modifying effect in several of these indication would add a lot of potential value to the FGLs program. The optimal portfolio of clinical indications should fulfill three objectives:
• Obtain proof-of-principal for the NCAM/FGFR target in any target patient population to which FGLs is being applied
• Develop FGLs toward the indication(s) which provide high unmet medical need
• De-risk the development by selecting an indication with relatively fewer critical issues in the target product profile, e.g. the current parenteral daily administration or potential obstacles affecting any first-in-class program such as unexpected severe side effects (Acute onset of effect in depression)
The pharmacological data of FGLs and the supportive science behind the NCAM/FGFR interaction suggests that FGLs is highly relevant in treating:
• Alzheimer’s disease and other dementia indications not related to the β-amyloid hypothesis (e.g. vascular dementia)
• Cognitive improvement in depression and schizophrenia
• Disorders with poor or dysfunctional synaptogenesis, such as Fragile X and Autism
The five groups of indications have very different commercial profiles and the sensitivity to the Target Product Profile (‘TPP’) differs significantly between them. An evaluation of a number of attributes has been conducted.
At this level of analysis the ratings are subjective, but the values assigned to each criteria guide the conduct of market research and it result lead to the prioritization of ongoing development.
Market research
A market research survey was conducted with the objective of providing a commercial evaluation of FGLs in 5 priority indications.
Five indications were selected: Alzheimer’s disease and 4 others. The market attractiveness for each of the indications was assessed and held up against the TPP of FGLs leading to a prediction of the strategy and positioning scenarios (incl. sensitivity of the TPP), identification and evaluation of key risks and commercialization issues to be explored.
Conclusion
The conclusion is that all of the indications appear to represent attractive target markets from a commercial perspective, given their unmet needs and potential. However, the risks are clearly different across these indications.
Enkam’s current positioning, which will have to be adjusted based on data generated in the coming years, is to focus the commercial FGLs development on Alzheimer’s disease aimed at a relevant cognitive improvement (either stopping progression or even improving it). This indication will both provide the huge upside potential and will hedge the risk in case of not succeeding in improving the delivery to either monthly depot or oral administration, or if severe unexpected side effect should occur in later clinical development.
Enkam’s focus for the earliest, cheapest and safest proof-of-concept for FGLs and NCAM/FGFR as a target is acute onset of effect in indication 2.
A third indication were selected as a back-up indication.
Alzheimer’s disease (AD)
Overall, KOLs were clearly interested in FGLs’ concept in the treatment of AD, having a novel and differentiated and promising mechanism’ which does not rely on β-amyloid. The KOLs showed a keen interest in FGLs even if it only offered symptomatic treatment. They were looking for at least similar efficacy as current therapies – although the subcutaneous administration and potential safety risks would raise the efficacy hurdle or limit the use of FGLs for a smaller sub-population of AD patients, but not rule out the use of FGLs.
As a disease-modifying agent, KOLs regarded a statistically significant treatment effect versus placebo as the minimum acceptable efficacy, and there appeared to be more willingness to accept the subcutaneous administration and potential safety risks compared with symptomatic treatment.
Key TPP Sensitivity
Across this research, the key ‘sensitivities’ in the TPP surrounded the mode of administration and level of side effects. The need for frequent subcutaneous administration – or the presence of severe side effects – clearly increases the level of efficacy required. The profile of these two parameters may limit – or open up – indications which could be targeted with FGLs.
Potential Impact:
3.1 Expected impacts listed in the work programme
Deterioration of brain function is a normal function of aging. Neurological disorders cause an impairment or dysfunction of the brain by an abrupt or accelerated destruction of neuronal cells and their network. Present available treatments for neurodegenerative disorders tend to focus solely on symptomatic mechanisms; where lost or damaged cells are neither repaired nor their function restored by the treatment. Patients still have to live with the disabling condition resulting from the disorder itself or often treatment limiting side-effects. As a result, organs or tissues that lack the ability to self-regenerate, such as in the CNS, have become a huge health burden to patients, families/caregivers and society as a whole. For this reason these organs/tissues that are unable to regenerate are being targeted for these neuroregenerative therapies, and this is the prime focus of NeuroFGL.
Neurodegenerative disease is a global issue; current estimates indicate 35.6 million people worldwide are living with dementia but with the world’s populations ageing, the World Health Organisation estimates that number will nearly double every 20 years, to an estimated 65.7 million in 2030, and 115.4 million in 2050.( Alzheimer’s Disease International. World Alzheimer Report 2009. London: Alzheimer’s Disease International; 2009). In 2010 the prevalence of dementia in Europe was estimated to be at 9.95 million, this figure is then anticipated to increase to 13.95 million in 2030 and 18.65 million in 2050. ( Alzheimer’s Disease International. World Alzheimer Report 2009. London: Alzheimer’s Disease International; 2009). There are 7.7 million cases of dementia diagnosed each year; poor recognition, under-diagnosis and stigma mean this figure is likely to be underestimated.
Between 50 and 70 percent of all people with dementia are suffering from Alzheimer’s disease. As the disease is believed to be one of the main causes of disabilities of the elderly, its impact is on not only the health costs, but also on economic activities in general, due to a decreasing ratio of working to retired population, and on the social activities of the patients and caregivers. Consequently, it will lead to a diminished quality of life of a large portion of the EU population. Therefore, the disease has become not only a major health issue but also a major economic and social issue.
3.1.1 Health Impacts
Please see attached figure 1
Improvements in health care in the past century have contributed to people living longer and healthier lives. The elderly are anticipated to reach 115 million by 2030 ( Commission of the European Communities (2006), The demographic future of Europe-from challenge to opportunity, COM(2006). ), or represent over 25% of Europe’s population, and these diseases will become an ever more critical issue. However this has also resulted in an increase in the number of people with non-communicable diseases, including dementia. Neurodegenerative disorders and many psychiatric disorders are the result of impaired cells leading to cell death and destruction of their network. There are over 600 known neurological disorders and conditions which affect up to one billion people worldwide, 24 million living with neurological disorder and 6.8 million people die every year due to these progressive disorders. Further development of promising neurodegenerative therapies such as FGL is therefore a key step in tackling these impacts on patients and society.
Alzheimer’s disease is a physical disease affecting the brain. During the course of the disease, protein ‘plaques’ and ‘tangles’ develop in the structure of the brain, more than likely leading to impairment and death of brain cells. People with Alzheimer’s also have a shortage of some important chemicals in their brain; these chemicals are involved with the transmission of messages within the brain. Dementia is most common in the older generation, but younger people (under 65) can get it too. Thus early symptoms of AD are often mistaken to be age-related concerns; the most common symptom being impairment of the short-term memory; having difficulty in remembering recently learned facts. As the disease progresses, further symptoms include confusion, irritability and aggression, mood swings, language breakdown, long-term memory loss and general withdrawal as the person’s senses decline. Gradually, bodily functions are lost leading to death. The mean life expectancy following diagnosis is approximately seven years with less than 3% of people living for more than fourteen years after diagnosis. None of the treatments available today for Alzheimer’s disease slows or stops the death and malfunction of neurons in the brain that cause Alzheimer’s symptoms and make the disease fatal.
Depression is a psychiatric disorder closely associated with death of neuronal cells. Consequently it has been considered logical to test FGLs in its capacity of inducing neurogenesis in the treatment of depression and it has shown both acute and chronic effect, confirming the underlying sciences findings of depression and NCAM/FGFR. Depression is a severely disabling disease, and causes a significant burden both to the individual and to society. Depression is the predominant mental health challenge among working-age people and more than 30 million European citizens will suffer from depression at some point in their life. The cognitive symptoms of depression (concentration difficulties, indecisiveness, and/or forgetfulness) cause significant impairment in work function and productivity and are present 94% of the time in an episode of depression. Depression affects quality of life more than most physical illnesses, and in some cases it even leads to suicide or suicide attempts. About 15% of patients with severe depression commit suicide, whilst 56% attempt suicide and the majority have suicidal ideas during depressive episodes. There are also well established links between physical illness and depression and vice versa. The complexity of depression is not fully understood, which contributes to misdiagnosis and inadequate care for people living with the disease. The situation is aggravated by the stigmatisation of the disease which makes many reluctant to seek help. Depression is included in the NeuroFGL as a de-risking strategy for the clinical work for AD and in itself holds the potential for an interesting additional benefit.
The long-term benefits of NeuroFGL will greatly assist the EU’s research efforts to combat neurodegenerative diseases for its citizens. The aim of the project is to prove FGLs’ effect on neurogenesis in a target patient population. This will maximise the chances of detecting a relevant proof-of-principle during the project and lead to the opportunity for a larger pharmaceutical company to make FGLs publically available as a treatment that would benefit both society and individual patients.
3.1.2 Economic Impacts
Please see attached figure 2.
The cost of dementia to the economy is twice that of cancer three times that of heart disease and four times the cost associated with stroke. (Jones, R.W. Mackell, J., Berthet, K., Knox, S., (2010) Assessing Attitudes and Behaviours Surrounding Alzheimer’s Disease in Europe: Key Findings of the Important Perspectives on Alzheimer’s Care and Treatment (Impact) Survey. The Journal of Nutrition, Health & Ageing. Vol. 14, (7).)
The costs associated with dementia increase with disease severity and double between mild and severe dementia. The total estimated worldwide costs are around £400billion (US$ 604bn) in 2010 – around 1% of the world’s gross domestic product – and £23bn in the UK. This figure includes costs attributed to informal care (unpaid care provided by family and others), direct costs of social care (provided by community care professionals, and in residential home settings) and the direct costs of medical care (the costs of treating dementia and other conditions in primary and secondary care). This cost is likely to increase as the number of people with dementia rises year on year; an estimated 85% increase in costs to 2030 has been forecast.
The graphs (Figure 3) illustrate the prevalence of Alzheimer’s disease and other dementias in Europe in 2008 (the latest published figures available), together with the total costs of the illness of which 56% were costs of informal care.
Figure 4 (attached) are for the US only, however, they illustrate a quickly escalating problem that is exactly the same elsewhere in the world including Europe. The figures point out the necessity to search for a solution to this illness, the faster the better.
Costs of illness are often sub-classified as direct medical costs, direct social care costs and indirect costs.
• Direct medical costs: refer to the medical care system, such as costs of hospital care, drugs and visits to clinics.
• Direct social care costs: arise from formal services provided outside of the medical care system; for example, community services such as home care, food supply and transport, and residential or nursing home care.
• Indirect costs: usually refer to production losses linked to the person with the illness (arising from impaired productivity while working, sick leave, early retirement, or death). The costs of informal care, arising from the unpaid inputs of family caregivers, friends and others can also be considered as indirect costs. In some European countries, AD care takes approximately 10-25% of a family’s average net annual income. In 2012, in the US, 15.4 million caregivers provided an estimated 17.5 billion hours of unpaid care, valued at more than $216 billion.
The total estimated worldwide cost of dementia was US$604 billion in 2010, about 70% of the costs occur in Western Europe and North America. (http://www.alz.co.uk/research/statistics) This statistic highlights age-related neurodegenerative disease as one of the leading medical and societal challenges faced by EU society. Alzheimer’s disease is particularly expensive to manage due to its insidious onset, its ever-increasing levels of disability and the length of time over which the condition extends itself. The average duration of this disease is between 2 and 10 years, during which patients will require social care that is a significant burden for both caregivers and for society as a whole. There is a need to strengthen the health system to deliver effective care for those living with neurological disorders such as AD. Given the high cost, the economic significance of research such as NeuroFGL is substantial.
The costs of depression were estimated at €92 billion in 2010 in the EU, with lost productivity due to absenteeism (taking time off work) and presenteeism (being present at work while ill) representing over 50% of all costs related to depression. This cost rose in 2011 to €113 billion across Europe (including the EU-27 Member States, Iceland, Norway and Switzerland). Depression is associated with longer time off work compared to other occupational health problems and also generates higher levels of disability/sickness benefit claims. Across Europe, mental health problems have been identified as a leading cause of taking early retirement or a disability pension.
Currently available drugs only relieve the symptoms of neurodegenerative disease and often only temporarily, thereby leading to the need for long-term care for patients. The development of neuroregenerative medicines, based on the very promising FGLs drug candidate can potentially provide long-term benefits to patients and help to substantially reduce the costs of healthcare and caregiving. Whilst the challenges involved in taking such a neuroregenerative medicine to market should not be underestimated, the potential economic benefits that would arise from the project, taken forward into commercialisation, could be €80- €120 billion per year from 2025, in the EU alone.
3.1.3 Employment and EU competitiveness
Ageing populations and dementia are global phenomena and NeuroFGL will help to create new jobs in Europe. NeuroFGL will also help to reduce the shortage of carers and nursing homes as a consequence of a reduced number of potential patients. The market size for AD drugs, only representing a minor and temporary effect, was in 2008 US$3.4 billion (€2.7 billion) in the US alone with Eisai/Pfizer, Aricept (Donepezil) and Forest Pharmaceuticals Namenda (Memantine) being the market leaders. See Figure 5 for the latest market analysis of current AD drugs on the market. The market will undergo a period of significant growth when the first neuroregnerative therapy becomes available as it will add significant value to patients and society.
The innovative approach in NeuroFGL provides new hope for neurodegenerative disease patients, their families and caregivers and health practitioners. The project will stimulate more attractive professional environments for scientists and help to address the ‘brain drain’. Many EU Member States are determined to secure and expand their position as an international hub for innovation, medical science and research, including Denmark and the UK. This is crucial for European incorporated pharmaceutical companies, such as H. Lundbeck, to maintain their competitive advantage and retain the best talent within Europe. Therefore the project potentially contributes to the development of a new competitive advantage, new periods of growth and new employment opportunities.
In the long-term, NeuroFGL would also help to decrease the burden related to the shortage of carers and nursing homes as a consequence of a reduced number of patients and reduced severity of the patient’s disease. Shortages of professional carers and nursing homes have been a major cause of high costs and a lack of proper care given by family members. Thus, this project can contribute to the improvement of clinical management of the elderly, which is one of the main objectives of the EU Health programme.
3.1.4 Social Impacts
Dementia is a devastating disease – not just for sufferers but for their families and friends too. And as more people live longer, it is fast becoming one of the biggest social and healthcare challenges the EU faces. Making a timely and accurate diagnosis of dementia is essential to enable people to gain access to the information, support and advice they need. The provision of care to a person with dementia can result in significant strain for those who provide most of that care; the stressors are physical, emotional and economic.
People with AD lose the ability to carry out routine daily activities including dressing, undressing, using the lavatory, travelling and handling money. As a result, many require a high level of care. This is often provided by an elderly relative, whose own health and quality of life are likely to be seriously affected by the burden of care provision. Carers show considerable psychological and physical illness compared to age-matched controls, with higher levels of anxiety and depression. A survey by the UK Alzheimer’s Society indicated that nearly 60% of carers reported suffering ill health or nervous problems as a result of direct caring. Further research has shown that up to half of caregivers become depressed. (Who cares? The state of dementia care in Europe. Alzheimer’s Europe. )
Dementia 2012, showed that the number of people who felt anxious or depressed was substantial, 77% of people surveyed said they felt anxious or depressed and 61% of people with dementia feel lonely. This can have a significant impact on the quality of life for people living with neurodegenerative disease. Factors contributing to increased loneliness among people with dementia include difficulties maintaining social relationships and reduced mobility. Around 90% of people with dementia will experience behavioural and psychological symptoms (BPSD) such as aggression, agitation or psychosis (delusions and hallucinations) at some point, which severely impact on quality of life. (Cause, cure, care and prevention. Impact of Alzheimer’s Society’s dementia research programme 1990-2012. )
The European Depression Association (http://www.multivu.com/mnr/56613-european-depression-association) reports that one in ten people surveyed in Europe have taken time off work because of depression, with an average of 36 days lost per episode of depression. This equates to more than 21,000 days of lost working time in this group of people. Despite the high rates of absenteeism due to depression, one in four of those experience depression stated they did not tell their employer about the problem. Of these, one in three said they felt it would put their job at risk in the current economic climate.
3.1.5 Policy Impacts
The implementation of NeuroFGL is likely to have a range of policy impacts. NeuroFGL responds directly to the EU Health Programme 2008-2013, geared towards promoting health, including the reduction of health inequalities, the prevention of human illnesses and reducing dangers associated with mental and physical health. In particular, the project meets the criteria for Major and Chronic (MCDs) Programme, as this project is geared towards those disorders affecting a minimum of 50 per 100,000 individuals resulting in over 85% of deaths in the EU, together with Mental Health Action. Healthy mental welfare is crucial to the growing economic and social development in Europe and NeuroFGL also responds to Employment policies by proposing new methods of treatment which will help individuals (patients and carers) to continue in their employment with reduced difficulty. Specifically the project responds to the following policies:
• COM(2009) 380/4 “Communication from the Commission to the European Parliament and the Council on a European initiative on Alzheimer’s disease and other dementias”, in particular supporting effective and efficient diagnosis, treatment and research for AD in Europe.
• In 2011, the European Parliament adopted the European Parliament resolution on a European initiative on Alzheimer’s disease and other dementias (2010/2084(INI)) – the call was to make dementia an EU health priority urging Member States to develop dedicated national plans and strategies.
• NeuroFGL will take an integrated approach by bringing together research efforts from both the public and private sector on a European scale, and will assist in the development of a European Research Area (ERA).
• Quality of Life and Management of Living Resources: NeuroFGL will contribute to the EC objective of improving the quality of life of EU citizens. It will do this by delivering applications that will combat established, emerging or re-emerging diseases in humans.
• Research and Technological Development of Activities of a Generic Nature, with activities that aim to reinforce the knowledge base in those areas of strategic but generic importance for the Life Sciences related to humans.
3.1.6 Steps needed to bring about these impacts
The technical approach of NeuroFGL is defined to reach the objective of proof of principle for a promising new drug with a neuroregenerative effect, together with the development of tests that will accelerate the development of other drugs. The development plan has been designed to maximise the success of the NeuroFGL project. Monitoring the achievement of these objectives will be scheduled prospectively. The research portfolio activities is also balanced between short term and more achievable research aims as well as long term and more promising research tasks.
One of the factors that could have an influence on the realisation of the above impacts is that all results will require regulatory approval and long-term clinical trials which will restrict their immediate application. The aim of this project is to take FGLs to the point that its development risk/commercial potential ratio will be appropriate for attracting a larger pharmaceutical company to invest the remaining >€200 million that will be required to bring FGLs to the market for the benefit of patients and society as a whole.
3.1.7 Necessity to have a European approach
The specific characteristics of Alzheimer’s disease and other dementias single them out as areas where actions taken at EU level can bring added value in supporting Member States. Much of the research to date has been led at a national level however, a greater international approach could see significant advances and more scientific breakthroughs if the EU were to collaborate more effectively and share information, research and expertise. Bringing together these different players could dramatically speed up and improve how diagnosis and therapy is approached, and how research is conducted. The different partners of this project are all world-class specialists in their domain and this European approach is the best way of achieving the project objectives.
Furthermore a European approach allows the involvement of a large number of patients with different backgrounds, living conditions and causes of illness. Clinical trials that involve such diverse patients will provide robust foundation of the research. A European approach also guarantees widespread diffusion of the result across the EU.
List of Websites:
http://www.enkam.com/content/us/neurofgl
