Sorry Person A …….International Emergency…You’ve had Ten Years to Publish it!

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Once this surfaces on a site like Pubmed…Person A (alias) and others will be saying…….what the F***. “That scumbucket MD has published my data!”.

Yep that’s true we have. It’s a lot easier than doing experiments, isn’t it!

However, I guess most famous neuros like Person A know the feeling. Others do the work and are not mentioned in the spotlight and the famous neuro’s name goes on the front :-). It’s good to have a bit of role reversal every now and then so you know both sides of the equation. Why is this done? Because it is a seal of approval etc

Indeed, some time ago ProfC in this case, that is Prof Coles from Cambridge posted a paper criticising the top Docs for sitting on the coat tails of Pharma and publishing a disproportionate amount of clinical trial reports. However, think of the positive. We have just saved pharma a wodge of cash as now they don’t have to pay a medical writer/employee to write-up the study. Yep I feel guilty, but it has been 10 years since the work was first reported.

When ProfC published this paper. Authorship of phase 3 trials in multiple sclerosis.Coles A. Ann Neurol. 2018 Apr;83(4):653-655. doi: 10.1002/ana.2520 Some of the Top Docs were outraged, some didn’t get it that ProfC was having a dig:-(. We still have to work out was ProfG…..Person C or D, E or even ironically maybe PersonG. We all know who Person A was…you would have to be Cuckoo not to know which Country they came from, or at least work in.

The subtext of paper by ProfC was that persons A-Y had become the puppet mouthpieces for the pharma machine, which gets medical writers to produce reports so that they conform to the law and ensure that they are dull as dishwater. So we have the structure (A) Demographics (B) Efficacy (C) Side effects (D) Dull.. because there is no interpretation. However, ProfG will argue that they play an important part in the trial design and I am sure that is true. But when we see the corporate Poster and platform Presentations we really know who is designing the content that you get to see. I am sure ProfC has been the recipient of this treatment too.

I will take abit of stick for this one…..as I have broken a rule, but as you know I was never a fan of Status Quo. However, is this a new opportunity… Snooze and you lose…..to encourage early publication.

Status Quo Rockin all over the World…I don’t like it, dont’t like it, don’t like it, don’t like it, don’t lie, lie lie…like it, lie, lie lie like it…Here we go….

Anyway, Person A reported this phase II study in 2012 (we got the poster) and a different person (we got the slides) reported the same stuff in 2013 indicating that pharma was in control because if it really was your work somebody else from a different lab would not be presenting it…Would they?…. So Pharma decides when to publish…They decided not. I think because the message was not something they wanted other people to hear and some of the later points were, I must admit, a bit data-lite and based on few observations and so have to be viewed cautiously.

There was no interest in reporting the study. That was until 2017 when we started to ask for the data of the trial extension because the sponsor of the trial had signed up to clinicaltrialdatarequest.com. During this time we were told that the trial data was available. However we had stirred something, and it wasn’t in my trousers:-). We were told that it was going to be published…So we backed off and gave Person A time to publish it. However, we made a formal request to clinictrialdatarequest.com. We extracted the data from the meetings reports and got the paper ready.

However, COVID-19 came along and we said times up, we so deposited on MedRXiv (14 January 2020) so it was visible and as we had got the nod that we could have access to the data, we put the paper in the public domain before we signed any of the legals with the sponsor. The plan was to get all the data out and then fill in missing bits.

Then the ABN came out (Mid March) and said delay ocrelizumab and at that point we still hadn’t seen any data and thought it was time to get it out as neuros weren’t reading pre-print sites. We went to editor of MSARDs and asked for a quick turn around, they said yes and the paper was submitted and then the plans went proper “tits-up”, and it has just surfaced because the speedy review was done at snail pace. Are we sure one referee in particular was not on the pay role of the sponsor:-(. However, by the time the paper surfaced we knew that COVID-19 was not an issue. Just before the re-review, we got access to the trial data. It is inside a virtual portal were you can’t copy anything and the files were coded but we weren’t given a key to know what was what. We are in lock down and trying to work on a few hundred thousand line spread sheet in a programme I have never used before on a 20cm lap top screen. It wasn’t going to happen quickly

So what does the data suggest? well yit says you are probably OK to delay infusion of ocrelizumab for a few months and disease should be held at bay for most people. I think this is good to hear. However in saying that it also says that dosing every 6 months may be over-kill and that you could reduce the frequency of dosing to get the same effect. I put the proviso here is that this may in part depend on how big you are. If you are petite the effect of the drugs may last longer. So the difference between the fastest to slowest repopulator was 27-175weeks (6 months to three and a quarter years so if you are that later person you have had 5-6 cycles of drug when there may have been no B cells to deplete. Perhaps you could have a drug-free pregnancy. We say do the study and show if this is true on not, do the ADIOS trial. If you don’t someone will

The ocrelizumab phase II extension trial suggests the potential to improve the risk:benefit balance in multiple sclerosis.
David Baker, Gareth Pryce, Louisa K. James, Monica Marta, Klaus
Schmierer Mult scler Rel Dis 2020.
https://doi.org/10.1016/j.msard.2020.102279 (Free copy here)

https://www.dropbox.com/s/cik6h2rfcsua5dd/Baker%202020%20Ocrelizumab%20MSARDS%20in%20press.pdf?dl=0

  • Ocrelizumab phase II trial extension data has 18-month post-drug follow-up.
  • Annualized relapse rate seems to remains low during the drug-free follow-up.
  • Infections and adverse events seem to be reduced during drug-free follow-up
  • Extended interval dosing may be possible that maintains efficacy and allows for more successful vaccination to new infections
  • Extended interval dosing may afford a drug-free pregnancy
  • Formal trials to demonstrate the benefit of extended interval dosing are warranted

Objective: Ocrelizumab inhibits relapsing multiple sclerosis when administered every six months. Based on potential similar memory B cell depletion mechanisms with cladribine and alemtuzumab, we hypothesised that CD20-depletion of B cells by ocrelizumab may exhibit a
duration of response exceeding the current licenced treatment interval.

Methods: Internet-located information from regulatory submissions and meeting reports relating to the unpublished open-label, phase II ocrelizumab extension trial (NCT00676715) were reviewed. This followed people (54-55/arm) with MS, who switched from placebo or interferonbeta
to ocrelizumab for three 600mg treatment cycles (week 24, 48, 72) or people treated with ocrelizumab for four 600mg treatment cycles (week 0-72), followed by an 18 month treatment free period.

Results: CD19+ B cells were rapidly depleted within 2 weeks and slow CD19+ B cell repopulation began about 6 months after the last infusion with median-repletion of over 15 months. The reduced annualized relapse rate during the published efficacy study appeared to be maintained in
the extension study and there were no new T1 gadolinium-enhancing or T2 lesions detected in the treatment-free period. Importantly, within these extension cohorts, there appeared to be fewer adverse events and infections events.

Conclusions: Ocrelizumab appears to induce durable relapsing disease inhibition, within 3 treatment cycles, Therefore, it may be possible to reduce the frequency of dosing to maintain efficacy, whilst limiting infection and other risks associated with continuous immunosuppression and could allow more effective vaccination against new pathogens. Further studies are now clearly required to determine whether this data is robust, as few people seemed to complete the study.

UPDATE YOu asked does thismean you have to have 3 infusions for this to occur. The answer isprobably no. The reasonI talked about 3-4 doses is because that was in the trial Iwas reported. If you want to know about one dose we can get an idea from a paper in arthritis https://pubmed.ncbi.nlm.nih.gov/18759293/

The dose used in MS is 2 x 300mg. So between the green triangle and the blue circle, so you can see that there was still marked depletion at 72 weeks. You can also see the 2 x 10mg dose depleted . 80 B cells per ul is the lowerlimit of normal and you can see a 6 months over 80% of people have notgot to this level to 1 year about 40% of people have got to half of lower limit of normal. The study is problematic as people on arthrits treatment get methotrexate also

It also makes a difference how big you are if you weight less than 60 kg youwill bea slow repopulator and if you are over 90Kg you will be a quick repopulator

Source FDA CENTER FOR DRUG EVALUATION AND
RESEARCH APPLICATION NUMBER: 761053Orig1s000

Small people get more drug on board and deplete better

COI: Multiple but not considered relevant. ProfG was not party to this, as he was conflicted…but shows we don’t all think alike. However on issues of safety, I am sure he will say publish and be damned..and I am sure I’ll be burned in Hell for doing this.

Update Thanks for the link https://www.msdiscovery.org/ms-galaxy ProfG in Yellow. So it is easy to see who person A and B and C are. Now I understand why the paper relating to Alemtuzumab part V was diluted from the original message.

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MouseDoctor

20 comments

  • Great paper. I think you should go to heaven for it, not hell 🙂

    Not at all surprised Roche isn’t very keen to publish the data…

    Would be interesting to hear about the 1000mg study arm, as well. Maybe that would move us further into IRT-land?

    • Thanks for this, I now also know why we had to dilute down the messages in the ADA paper due to one of the co-authors…one of the dots.

  • Sounds like this is a classic storm in a teacup in the MS research world! I wonder if it will make any difference as the constant drip feeding of Alemtuzumab side effects means this drug will be used less and less in the future. This is a real shame as I and many others I know have had great results from Alemtuzumab and the side effects can be picked up with good monitoring and treated. Barts (particularly MD1) seem to dislike the Cambridge team. In reality Cambridge gave us Alemtuzumab and Barts took years to come up with a less effective poor cousin – oral Cladribine. It’s a pity MD1 has done a Killing Eve job on the Cambridge team and undermined a highly effective treatment. Hell hath no fury like a Mouse Doctor scorned. I have no idea why MD1 is so anti-Cambridge – jealousy?

    COI Dr C is my neuro and I love the Cambridge Team. They spend their time doing new stuff rathe4 than trawling over the work of other teams in a sad attempt to undermine it.

    • MD1 is not a neurologist so can’t make a call in relation to the use of alemtuzumab. Prof G is a neurologist and a big fan of alemtuzumab; in fact, Barts is one of the largest alemtuzumab prescribing centres. Are your criticisms justified unless you have other evidence that you can prevent?

      • Dear Feh, Kev, Lulu trixiebelle Angry from Siddcup or what ever you want to call yourself today. Why do you think cladribine is less effective? The data does not support this view in terms of NEDA. Yes we use alemtuzumab because it has merit, if fact ProfG helped genzyme get alemtuzumab approved by the EMA but that’s another story.

        This is a post about ocrelizumab aimed at providing information for anyone who is taking ocrelizumab and is being asked to delay their drug. It provides some sense that this is probably not a risky request. The neuros on the ABN panel I am sure know this data but the average Jo and Neurologist do not.

        As for the drip feeding about alemtuzumab…I am reporting our work…if you want every bad thing that happens about alemtuzumab you can read about them, I don’t need to do this the Neurological community has done this and this is why alemtuzumab has a black box warning. We know alemtuzumab is a good drug but it can be made safer…so just get over it

        He’s one you can read, maybe I’ll do a post, maybe come back as Dr Dre…oh I forgot that ones taken.

        Severe paradoxical disease activation following alemtuzumab treatment for multiple sclerosis. Brannigan J, Jones JL, Stacpoole SRL. Neurol Neuroimmunol Neuroinflamm. 2020 Jun 10;7(5):e799. doi: 10.1212/NXI.0000000000000799. Print 2020 Sep.
        PMID: 32522766

        We made the anti-drug anti body response to help the neurologists make a call about whether to re-treat or switch. They make the call not me, but it is a tool that can be used to help people with MS.

        I am happy you love your team, as for doing new stuff, best not respond to that.

  • Sorry if I’m being a it dim, and maybe not really concerned with the politics of publishing. I’m just an anxious patient being asked to delay occy. Am I reading right that the continuing affect and therefore safety in delay is reliant on the having been at least three rounds?

    Thanks 🙂

    • This is a great question. My neurologist used this paper to justify my delayed dosing (for an indefinite amount of time!)… on the basis that there will remain B cell depletion. However it is clear that this is only after 3 cycles, I have had 1!

      This will be relayed in a firm but fair way, I would like my second planned cycle please. The ABN deem it “reasonably safe” why withhold it?

    • No the data in the paper relates to 3 rounds and then nothing and4 rounds and then nothing. Thedata relating to one round is in Genovese MC, Kaine JL, Lowenstein MB et al. Ocrelizumab, a humanised anti-CD20 monoclonal antibody, in the treatment of patients with rheumatoid arthritis: A phase I/II randomised, blinded, placebo-controlled, dose ranging study. Arth Rheumatol. 2008; 58:2652-2661.

      There is data with one round of rituximab, which is less depleting than ocrelizumab and that is in Bar-Or A, Calabresi PA, Arnold D et al. Rituximab in relapsing-remitting multiple sclerosis: a 72-week, open-label, phase I trial. Ann Neurol. 2008; 63:395-400. This shows a long time for the memory cells to re-appear.

      I will add the pictures

      • I feel so stupid to ask you this. I am a very small woman. I had my second full dose of ocrevus 2 weeks ago. So I’ve had the initial 2 half doses followed by a full dose 6 months later, then a second full dose 6 months later. In the month leading up to the second full doz, I felt horrible. My symptoms worsened a lot. I’m now close to how I felt a few months after the first full dose. I’ll leave out how the first two halves left me feeling and just say that I could barely walk for weeks. The solution offered to me was a slower infusion speed. It seemed to help.
        My question is why did it seem to wear off or whatever so fast? I’m short and slightly underweight. My neurologist has not ordered any blood tests since I started taking it. I feel like I should demand it, but should I?
        I’m rambling now, but I wanted to start Mavenclad instead of Ocrevus because the doses are based on weight. I was and still am debating a change from O to Lemtrada. I was discouraged from taking Lemtrada due to its safety profile, yada, yada, yada. And told that if it didn’t work well, I couldn’t take anything except copaxone afterwards.

        I would love to hear your thoughts.

        • I am not a neurologist and can’t offer advice. People who are under weight should deplete a lot better than people who are overweight as they are effectively getting more antibody according to their body mass. At present many places are implementing a faster infusion, to limit hospital contact and I believe that the manufactureres are also doing studies on subcutaneous dosing. As for not doing tests, I would like to know that the drug is working and that your B cells were low, but at the moment fewer blood tests means less contact with people.

          Why does it seem to wear off quickly?. It shouldn’t ocrelizumab depletes B cells quickly and it should be at sufficient levels to deplete B cells for months the benefit should be fewer relapses. As for progression this may continue but at a slower rate

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