Background Information

• AMX0035 is a combination of two small molecule drugs: Phenylbutyrate (PB) and Tauroursodeoxycholic Acid (TUDCA).
• The Centaur Trial (NCT03127514) looked at the functional impact of AMX0035 on the ALSFRS-R score of people living with ALS vs. a placebo. The total trial enrollment was 137.
• The statistically significant Centaur Trial results are documented here. In short, the drug causes significant slowing of ALSFRS-R decline.
• The open label extension of the Centaur Trial was utilized to observe the impact of AMX0035 on the long-term survival of people living with ALS.
• The readout contained 35 months of data (beginning from initial trial enrollment period in 2017/2018).
• The readout came from a comparison of trial participants who took AMX0035 vs. those who were administered a placebo.

• The following results were disclosed by the principal investigator of the Centaur Trial, Dr. Sabrina Paganoni, during the webinar:
  • There was a 6.5 month longer median survival in the group originally randomized to AMX0035 than the placebo group. The median survival durations were 25 months and 18.5 months respectively.
  • Please read the Oct 16th Amylyx Pharmaceuticals press release of their long-term survival data findings here.

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Prop 14 plans to use debt to fund biomedical research: $5.5 billion in state general obligation bonds to be exact. The basic math is this: $5.5B granted today will accumulate $2.3B in interest. This interest will be payed back over 30 years in annual installments of $260 million by “Primarily General Fund tax revenue” aka, your taxes.

How is the $5.5B being distributed?

The grants will be distributed by the California Institute of Regenerative Medicine (CIRM) to “educational, nonprofit, and private entities for: stem cell and other medical research, including training; stem cell therapy development and delivery; research facility construction and associated administrative expenses”(Official Voter Information Guide).

This debt funding concept is not new. Prop 14 is preceded by Prop 71 which awarded $2.7B in stem cell grants since 2004. That money was utilized for important cancer research projects at a time when the federal government refused to fund stem cell research. The catch? The research was supposed to pay for itself with projected revenues from successful therapies. That has not yet happened.

Revenue projections aside, stem cell research is incredibly important to the ALS community. Please watch this webinar to hear experts discuss stem cell projects involving basic research and potential therapies for ALS that depend on Prop 14.

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Since 2016, MOFF has granted $105,000.00 to ALSTDI. In 2017, MOFF funding was earmarked to finance preclinical studies for AT-1501. The project was selected by MOFF due to the selective and specific nature of the AT-1501 antibody. These characteristics were a result of the years of development the potential therapy had undergone at the Biogen and later the ALSTDI labs. The MOFF board found the novel method of targeting the co-stimulatory pathway as an attractive investment.

AT-1501 not only holds promise in ALS, but also for Type I Diabetes, and other neurodegenerative and autoimmune diseases. The MOFF board is looking forward to following the development of this therapeutic option.

Learn more about AT-1501 in an ALSTDI Enpoints podcast episode here.

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CRISPR is a highly specific and efficient genome editing technology. CRISPR facilitates the addition, deletion, or alteration of an organism’s DNA (NIH). If you would like a more specific explanation of CRISPR, feel free to watch the 1:39 video from the Mayo Clinic below.

As one can imagine, this is exciting and simultaneously, terrifying technology. It holds incredible potential for countless rare, genetic diseases. The concept of curing a disease by removing a faulty gene, is not new, but CRISPR is definitely one of the more cost-effective and reliable ways to do so. Thus far, CRISPR technology has been tested on many rare disease areas, including cancers, sickle cell anemia, Huntington’s Disease, Alzheimer’s Disease, and ALS. In 2018, Target ALS provided CRISPR Therapeutics with a 2-year grant to study ALS and Frontotemporal Dementia (FTD). We are excitedly awaiting those results.

Current CRISPR Challenges

The success of CRISPR technology depends on the structural validity of in vivo disease models, meaning how well the animal model of the disease actually portrays the disease in humans. The ALS field has historically struggled with this issue. CRISPR success also depends on the capabilities of high throughput genome mapping technology, meaning, how much knowledge we have about the genome we will be editing. As we observe these two key elements (animal model validity and genome mapping technology) becoming more efficient and reliable, we will begin to see very obvious therapeutic results from CRISPR.

Another roadblock to CRISPR’s usage in ALS is the fact that sporadic ALS is a messy disease. Messy meaning there are often a number of genes that contribute to the disease manifestation. Not only that, but these genes are not all ‘bad’ genes, but they are mutated in some way. For example, the protein C9orF72 is indicated in both familial and sporadic ALS. The normal function of this gene is to “influence the production of RNA from genes, the production of proteins from RNA, and the transport of RNA within the cell” (NIH). In ALS, C9orF72 is expressed as a hexanucleotide repeat expansion. If you program CRISPR technology to eliminate C9orF72, you may eliminate ALS, but you will also eliminate all the normal function of the protein, which could be deadly.

CRISPR Breakthroughs

Treatment of a Mouse Model of ALS by In Vivo Base Editing

In this study done at the University of Illinois, ALS disease progression was slowed in mice when CRISPR was applied. Researchers utilized cytidine base editors (CBEs) to remove SOD1 gene expression. “CBEs are a type of CRISPR single-base editors that change specific nucleotide bases in a DNA sequence” (ALSNewsToday). The result of using this type of CRISPR technology is that it does not delete the SOD1 gene, but rather it induces a ‘stop’ signal early in the gene expression so that it cannot progress to be a mutant SOD1 gene. Very cool.

The most common CRISPR headline you will see in relation to ALS is this one:

CRISPR reveals possible ALS drug target

In this particular study, a research team at Stanford used CRISPR to effectively ‘knockout’ or cut random genes out of the genome so that they observe “genes that protect neurons against the toxic effects of protein aggregates by being inactivated” (FierceBiotech). Their study revealed that “knocking out a gene called TMX2 prevented cell health in mouse neurons.” In the ALS world right now, finding possible therapeutic targets is a huge deal and most researchers are hard at work knocking out genes to do so.

The final, and arguably the most exciting, CRISPR breakthrough is highlighted in these two articles:

CRISPR-based method allows for reversible RNA editing

RNA-targeting CRISPR could yield treatment for Huntington’s and ALS. 

The methodology behind this concept is mind-blowing. This article is from 2017, but they are still fine-tuning the science today. Researchers at the Broad Institute have dubbed the technology: REPAIR (RNA Editing for Programmable A to I Replacement). How does it work? To start, one has to understand the basics of transcription and translation. Here is a crude summary: DNA is transcribed to RNA which is then translated into proteins. This technology does not cut DNA, but instead, it binds to RNA and effectively changes one nucleoside in the RNA helix. Therefore, when RNA goes to translate into a protein, it will encode for a properly functioning protein instead of a mutant protein involved in disease progression. Amazing.

Woof, that was a lot of science. Thank you reading if you made it to the end. To conclude: CRISPR Technology holds incredible potential for ALS and other rare diseases. Researchers just need to perfect it in a lab so that when it is applied to humans, no one comes out missing a limb :).

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Who attended this International Advisory Council Meeting?

Dr. Jeanine Heckmann (South Africa)

Dr. David Taylor (Canada) – facilitator

Dr. Kuldip Dave (USA)

Dr. Nicolas Cole (UK)

Dr. Caroline Ingre (Sweden)

Dr. Gethin Thomas (Australia)

Dr. Piera Pasenelli (USA)

Absent: Dr. Qing Liu (China), Dr. Adriano Chio (Italy) and Dr. Luis Barbeito (Uruguay)

What did they discuss?

The main discussion topic was prompted by the facilitator, David Taylor. He began the meeting by encouraging participants to share what they are most excited about in the ALS/MND field. Responses varied, but there was a general consensus around 3 topics:

1. Platform trial design

The Tricals Platform Trial (UK) and the Healey Platform Trial (USA) design are both incredible tools to test new therapies for ALS. They are not only cost-effective, but time-efficient and patient-centric as well. The platform concept was originally implemented in oncology, and in 2019 was adapted to the ALS field. Historically, trials have required a 50/50 placebo control. In cancer and ALS, the fatality rate of these diseases make it almost unethical to put a patient in a placebo control group. The platform trial takes this into consideration; only 1/3 of patients will receive a placebo and for a shorter duration (6 months). The platform trial design allows for more therapy options to be tested at once: 5 for the Healey Trial and 2 for the Tricals Trial. The treatments being tested in the Tricals Trial are Lithium Carbonate and Triumeq. Read the MOFF article on the Healey Trial to learn what treatments are being used in the U.S. trial.

Dr. Pasenelli and Dr. Cole had a productive dialogue about comparing trial outcome measures. This discussion occurred after Dr. Cole claimed the Tricals Trial had more outcome measures than the Healey Trial. While this is likely because the FDA bases it’s outcome measures on the ALSFRS-R score and the EMA bases their outcome measure reporting on survival, a more thorough comparison is warranted.

2. Gene therapies

Gene therapies are the future! It is not an unrealistic claim to say that specific genetic forms of ALS will be curable within the next 2-5 years. Researchers are targeting ALS cases with the SOD1, FUS, and C9orF72 genetic mutations. Two examples of such therapies are Tofersen (Biogen) and AVSX-301 (Avexis/Novartis). Phase 3 trials of Tofersen are currently being conducted in the U.S. and multiple other countries including Japan, Canada, and Italy. The aims of these gene therapies are to replace genes, silence genes, or deliver proteins that boost motor neuron function. Currently, the two most promising ways to deliver these therapeutic benefits is via Adeno-associated viruses (AAVs) or Antisense Oligonucleotide (ASOs).

These gene therapies are the first to modify ALS disease progression. This is amazing given the fact the three current FDA approved medications for ALS simply claim to extend patients’ lives by 3 or 6 months. What is even more incredible about the development of gene therapies for ALS, specifically, Tofersen, is that Dr. Alan Smith wrote about this therapy in his book: Handbook of Amyotrophic Lateral Sclerosis. It was published in 1992. Patients are finally gaining access to treatments that have been conceptualized almost 30 years ago.

Keep in mind that these genetic therapies will only be effective for 10% of the ALS population. That being said, C9orf72 has implications in the sporadic form of ALS as well so whatever pathogenetic insights they extract from these ongoing clinical trials, will inform future studies done for sporadic ALS.

3. Biomarker usage

We can finally objectively measure if drugs are slowing ALS disease progression! “Biomarker” has been a buzz word in the ALS community for years. A biomarker, loosely defined, is a biological sample that can be used to screen, diagnose or monitor disease progression. The majority of  excitement during the meeting was centered on the use of pharmacodynamic biomarkers, in upcoming clinical trials. Below is an image of the many potential measurements of ALS disease progression that newer trials, specifically the Healey Platform Trial, will incorporate.

(Image adapted from a 2019 Mass General presentation on the Healey Platform Trial. The presentation was led by Dr. Sabrina Paganoni and Dr. Ben Saville)

For the sake of time and space, this post will not going into the details of each measurement. More information can be found in this Frontiers article. The second takeaway from council’s the biomarker discussion was one of hope. Dr. Pasenelli described an important perspective shift that has occurred in the ALS research community. To paraphrase, she recognized that 7-10 years ago, researchers joined the ALS therapeutic area for the general, rather unexciting discipline of researching. Now, each ALS research investigations could lead to a potential therapeutic target or a biomarker discovery. The hope of actually discovering something is alive and is encouraging more individuals to join the field. This was incredibly encouraging to hear.

Sidenote:

South Africa:  South Africa gets their own blurb because during the meeting it sounded like Dr. Jeannine Heckmann was on a literal ALS battlefront. She began the meeting by stating there are only 3 interdisciplinary clinics in South Africa and the some of the medical professionals attend the clinics once a month. Dr. Heckmann went on to share a very moving story about recent ALS diagnosis she had to give while the patient was already in need of a ventilator and there were limited ventilator resources. Their country has limited resources to Rilutek, which is 10-15 years behind USA standards. In conclusion, Dr. Heckmann is a saint and needs back up. Also, the South African ALS patient community needs support ASAP.

Thank you to all the ALS/MND Internationals Alliance Scientific Council Members! We greatly appreciate all of your contributions to the ALS field. 

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(May 26, 2020 – June 3, 2020)

The National ALS Advocacy Conference was virtual this year! The Martha Olson-Fernandez Foundation (MOFF) attended two days of the virtual event. Continue reading to get the inside scoop on the political interests of the ALS community.

What is The National ALS Advocacy Conference?

The National ALS Advocacy Conference is a week-long event in which patient advocacy groups lobby to raise disease awareness, present funding requests, and push policy initiatives that will support the ALS patient community. The event has a similar structure each year:

• Daily conferences are held that discuss ALS research updates, ALS community needs, specific policy initiatives, and congressionally appointed fund requests for the year.
• ALS patients and their families visit the offices of members of Congress to personally tell their stories and request support for the funding or policy initiatives that will benefit the ALS community.

Who were the main players in the “ALS community” during the 2020 ALS Advocacy Conference?

• Muscular Dystrophy Association
• I AM ALS
• Team Gleason
• ALS Association
• Les Turner Foundation
• American Academy of Neurology
• National Health Council
• National Organization for Rare Disorders

What were the main “asks” of the ALS community for FY 2021? (The requests that are placed in May 2020 pertain to the fiscal year (FY) 2021).

The ALS community is advocating for the following public policy priorities in FY 2021:

• ALS Disability Insurance Access Act (S. 578/ H.R.1407): Request to waive 5-month waiting period for Social Security Disability Insurance (SSDI). This Act builds off the previous motion passed in 2000 that waived the 24-month Medicare waiting period. This is an urgent agenda item and currently has support from 61 senators and 238 representatives.
• Expand Access to Home Infusion for Medicare Beneficiaries
• Promising Pathway Act: Proposal to amendment to the Federal Food, Drug, and Cosmetic Act to establish a time-limited provisional approval pathway for certain drugs and regulated medical products.
• Accelerating Access to Critical Therapies for ALS Act: Creates a pilot program to support expanded access programs. Will dedicate $75 million available in FY 2021 and FY 2022 toward this program.
• Justice for ALS Veterans Act (S. 3091/H.R. 4748): This bill ensures that surviving spouses of veterans with ALS receive fair dependency and indemnity compensation.
• Request for $40 million congressionally appointed dollars for the Department of Defense ALS Research Program.
• Request for $10 million congressionally appointed dollars for the National ALS Registry.
• Request for $44.7 billion congressionally appointed dollars for the National Institutes of Health (NIH).

What politicians are supporting the ALS cause?

The below list and commentaries provide a snapshot into the wide-ranging political support the ALS community has garnered.

• Senator Mike Braun (Indiana) is championing the ALS Disability Insurance Access Act. In the virtual meeting on May 26^th he stated: “I don’t think there is a good reason why this should not pass.”
• Representative Peter Welch (Vermont) is supporting the ALS Disability Insurance Access Act. His commentary during the virtual meeting was, “Congress is a tough institution to move,” but the ALS community’s “long term advocacy is working.” He also stated that we currently have 238 supporters in the House, if we obtain 290, it “can be put on a consent calendar.” In lay terms, this would deem the Act as a topic that is not controversial and does not need to be discussed and can be accepted without a vote.
• Representative Jason Crow (Colorado) affirmed that the ALS community “has a friend and an ally in Congress.” He is a prior Army Ranger whose wife’s cousin passed away from ALS.
• Congressman Jeff Fortenberry (New England) introduced the Accelerating Access to Critical Therapies for ALS Act.
• Congressman Mike Quigley (Illinois) co-sponsored the Accelerating Access to Critical Therapies for ALS Act.

How do the 2020 ALS community funding requests compare to historical asks?

• To give you an idea of how much the ALS community’s political involvement has grown, in 1998 the government allotted $15 million dollars total to ALS research initiatives.
• In FY 2020, the ALS community requested $20 million congressionally appointed dollars for the Department of Defense ALS Research Program. This was request was granted.
• In FY 2020, the ALS community requested $10 million congressionally appointed dollars for the National ALS Registry/Biorepository development. This request was granted.
• In FY 2020, the ALS community requested $105 congressionally appointed dollars for the NIH. The request was granted.

Conclusion

The 2020 National ALS Advocacy Conference was marked by monumental support and engagement from members of Congress. Despite the virtual platform, the ALS patient voices and actions could not be ignored. One key takeaway from the conference was the importance of forming coalitions with other patient groups. It is by unifying the patient voices, and combining them with the urges of doctors in their respective fields, that disease-community demands will be answered. This year, the American Heart Association and the American Lung Association formed key alliances with the ALS advocacy community on specific interests.

Thank you to all the parties involved in this monumental conference. Your efforts are saving lives. More information can be found on the ALSA, MDA and I AM ALS websites.

Sponsors

The main sponsors of the National ALS Advocacy Conference were the following pharmaceutical companies: Alexion, Amylyx, Biogen, biohaven pharmaceuticals, Genentech, Mitsubishi Tanabe Pharma America, and Soleo Health.

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SBMT 16th Annual Congress

Los Angeles Convention Center in LA

FLYER

16th Annual Congress of Society for Brain Mapping promotional video – 2019 from Brain Mapping Foundation on Vimeo.

Topics & Speakers

Moderator: Mike Piscotty, ALS Cure

Biomarkers to aid diagnosis and monitor drug efficacy in clinical trials for ALS
Robert Bowser, Ph.D. The Barrow Neurological Institute

Biomarkers for CNS injury and disease
Kendall Van Keuren-Jensen , Ph.D. TGen

A data-driven approach links microglia to pathology and prognosis in ALS
Johnathan Cooper-Knock Ph.D. University of Sheffield, UK

Allosteric assembly machine modulators for ALS therapeutics
Vishwanath R Lingappa, M.D., Ph.D. Prosetta Sciences

Financing ALS biomarker discovery
Natalie Fernandez, 2019 MBA Candidate, The Martha Olson-Fernandez Foundation

The interdisciplinary nature of the SBMT conference allowed the ALS biomarker panel members to learn and collaborate with fellow industry members. The biomarker research topics were promising. Stay tuned for research article postings on the studies discussed.

Director Bobak Kalhor interviewed each of the panelist for an ALS media project. Bobak is director of “A Dying King- The Shah of Iran.” He recently lost his mother to ALS.

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1. Whole genome sequencing (WGS) analysis projects are being undertaken by the following collaborative bodies: Track ALS, NeuroLincs, CABB, ALS Natural History, Answer ALS, NYGC ALS Consortium, and Target ALS. The data will be available to the public via the database ALSoD in early 2019.

2. There are several active stem cell trials being conducted in the U.S. by Braincell Therapeutics and also Avexis Pharma

3. Dr. Steve Finkbeiner from UCSF discussed machine learning in the context of ALS research. More specifically, he discussed how efficient and accurate the technology will be when it comes to exploring therapeutic targets and genetic patterns in neurodegenerative diseases.

4. There is currently a lot of research being done on the role of microglia, astrocytes, and macrophages in ALS. These research efforts attempt to understand the underlying pathology of the disease.

5. TDP43 was discovered to be present in all ALS models. It is now being looked at as a target that can be corrected with gene alteration.

Most of the top researchers in the ALS research world on the west coast were represented at the conference. The list below contains 5 ALS research pioneers. If you are interested in their research, each of them has many publications under their names.

* Leslie Thompson, PhD, UC Irvine
* Steve Finkbeiner, MD, PhD, UCSF
* Aaron Gitler MD, PhD, Stanford University
* Clive Svendsen MD, PhD, Cedars-Sinai Medical Center
* Dr. Richard Smith (CNS)

Day 2 Takeaways:

1. The Lazarus Project was presented by Dr. Ranjan Gupta, MD from University of California Irvine. His research debunked the theory that motor function cannot be recovered after 6 months of de-innervation. His surgical procedures are truly miraculous. In some cases, he was able to execute nerve transfer surgeries to bring function back to limbs that had not been utilized for 6 years. Learn more about his research here.

2. Dr. Steve Finkbeiner’s lab revealed results from his high throughput microscopy project which targeted autophagy in ALS cells. Read more about his research here.

3. Mitsubishi Tanabe Pharma America, the company that makes Radicava, was represented by Dr. Stephen Apple, the senior medical director at the company. Dr. Apple discussed post market surveillance and their Phase 4 trial that they laid the foundations for. The Phase 4 trial plans to utilize biomarkers to detect the efficacy of the drug within ALS patients. Results from the study should be release in 2021.

4. New ALS targets were identified by Dr. Aileen Anderson from University of California Irvine. She studies spinal cord injuries and encouraged researchers to look into the autocrine signaling pathways in neuronal cells. More specifically, Dr. Anderson’s research explored neuronal stem cells to see if they had specific receptors that could be blocked. Her research found 5 novel receptors in neuronal stem cells that could be potential targets.

5. Routes of ALS drug administration were discussed in the context of antisense oligonucleotide therapies (ASOs) in order to answer the questions: How much virus is necessary, and where do you need to inject it in order to adequately cover the CNS? A new method of subpial drug administration (injection of the drug under the pia mater in the CNS) is being explored. Previously, intrathecal administration was the standard for ASO drug administration such as AVXS-10.

At the end of the day Ask the Experts took place in a separate building. At this panel, ALS patients and their families were able to discuss the most current scientific findings with the researchers themselves. Even though much progress has been made, the disconnect between the research world and the ALS patients was still noticeable.

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