Today the Mouse Doctor and I will be attending an extraordinary meeting of MS Society’s Clinical Trial Network (CTN) to discuss research priorities and how we proceed to tackle progressive MS as part of the MS Society’s STOP-MS campaign. The difficulty we find ourselves in is that it clashes with our Institute’s strategic away day; an annual day when we go off campus to discuss strategy and set priorities for the next year. The fact that we have both agreed to attend the CTN meeting either tells you where our priorities lie, or how important this CTN meeting is.
A lot is happening in the progressive MS space with several new developments and insights that all need to be taken into account when setting sail on a journey that once you leave harbour and have set your course it is difficult to return and start the journey again.
The following is a list or recent developments that have affected the progressive MS space and mean we need to rethink things:
- Ocrelizumab the first effective DMT for progressive MS has been licensed by the FDA for PPMS (let’s hope the EMA does the same later this year) and we also have a positive spinonimod SPMS trial. As a result of these two trials we now have to accept that progressive MS is modifiable, but I am aware that many killjoys in the field don’t think the outcomes in these trials are clinically meaningful.
- There are several ongoing progressive MS trials looking at interesting compounds, treatment strategies and trial designs. I think we should wait for these to read out to learn from them.
- There are at least 4 industry sponsored and investigator-led progressive trials, that I am aware of, starting. The activity in this space is unprecedented and I am concerned there may not be enough people with progressive MS for all these trials. Please note that almost all of these trials are using an EDSS cutoff of 6.5, which excludes the majority of pwMS who have progressive MS from participating.
- The MS Outcomes Assessment Consortium (MSOAC) that was launched in December, 2012, has finally reported. MSOAC was established to collect, standardize and analyze data about MS with the goal of qualifying a new measure of disability as a primary or secondary endpoint for future trials of MS therapies. The important thing about MSOAC is that the regulators, in particular the FDA, now accept a composite end-point for progressive trials. The importance of this cannot be overemphasised.
- The International Progressive MS Alliance (PMSA) have now funded their collaborative networks and these will take 3-4 years to deliver important insights into new mechanisms underlying progressive MS.
- Publication of the length-dependent axonopathy, therapeutic lag and asynchronous progressive MS hypotheses. The paper is not just about the musings of Barts-MS, or us blowing our horn. The insights outlined in this paper explain why the current trial paradigm in progressive MS has resulted in negative trials. If we designed the trials properly we would have gotten positive results in progressive MS decades ago. When we developed these hypotheses we engaged the wider MS community including industry. It is notable that we have representation from Biogen, Merck, Novartis, Roche and Teva on the paper. Including Pharma was no accident, we want them to invest in progressive MS and design successful trial, including trials in more advanced MS (wheelchair users).
- Development and validation of a sensitive serum/plasma assay for neurofilament levels. This may be the game-changer we need for doing phase 2 proof-of-concept trials in progressive MS. The idea would be to do an area-under-the-curve analysis of neurofilament levels to assess the efficacy of a treatment at reducing neuroaxonal loss in MS.
- Validation of the 9-HPT as clinically meaningful outcome measure of upper limb and hand function. The results of the 9-HPT correlate very well with the ABILHAND a patient-related outcome measure (PROM) that has face validity, i.e. it is clinically meaningful.
Some of the issues that I think need discussing are:
- When does progressive MS begin?
- Is MS one, two or three diseases?
- Should we be combing SP and PP MS populations when we do progressive MS studies?
- Should we be doing combination, rather than monotherapy, studies?
- If we go with an anti-inflammatory platform, which is the best anti-inflammatory?
- Do we need neuroprotection in addition to remyelination, or can we target remyelination on its own?
- How do we design neurorestorative trials? What can we learn from Biogen’s opicinumab (anti-LINGO-1) trials and other exploratory remyelination trials (e.g. clemastine)?
- When doing neurorestorative trials do we need to include a targeted neurorehabilitation programme to promote recovery?
- Should we be investing in a useful patient-reported outcome platform as part of the MS register to do registry trials?
- Should we be including people with MS with more advanced disease, i.e wheelchair users?
- Should we be doing randomised DMT withdrawal studies to see if people with progressive MS are still benefiting from DMTs?
- What about co-morbidities, in particular hypertension, diabetes and metabolic syndrome? Ruth-Ann Marrie has shown that treating co-morbidities may be as effective as a DMT in delaying disease worsening in pwMS.
- What about lifestyle issues, for example smoking, diet, sleep and exercise? This is the elephant in the room and is the reason why we are actively promoting lifestyle issues as part of our Brain Health campaign.
- What about the contribution of recurrent infections to progressive MS? Should we include preventing recurrent infections as part of this initiative?
- What about premature ageing? How do we dissect out ongoing MS pathology from ageing mechanisms in progressive trials?
- Trial design, do we go with the standard randomised placebo-controlled trials and include time-to-event analyses? Do we use adaptive design? Standard vs. Bayesian statistics?
- How do we derisk trials, i.e. give them the best chance of being positive? How can Pharma help us with derisking trials?
- How do we create policy to allow the repurposing of off-patent drugs? If we don’t do this is it worthwhile doing trials on drugs with no defined commercial development path?
- What can we learn from other fields, or are we sailing on uncharted waters?
- Which experts from MS and other fields can we consult for help?
- How to deal with conflicts of interests? Almost everyone in the UK has a conflict and a personal or institutional agenda?
- Are the outcome measures that work for RRMS fit for purpose when it comes to progressive MS trials? Do we need to develop new more targeted outcome measures for more advanced MS?
- Can we select drugs, or potential drugs, for progressive MS from the published literature or patent literature?
- Can we crowd-source drug discovery for progressive MS?
- Managing expectations. How do we manage the community’s expectations? We don’t want to overhype things. What is a realistic expected outcome when tackling progressive MS? Is it slowing-down worsening disability? Stabilising, or flat-lining, current levels of disability? Or should we looking at restoring lost function?