Phase IV study: Essential lab outcomes

Gavin Giovannoni

Barts and The London School of Medicine and Dentistry

Why lab outcomes?

• Diagnostic testing

– Positive & negative predictive testing

• Pathogenesis

– Immunology

– Aetiology

– Disease progression & recovery

– Disease heterogeneity

• Pharmacovigilance

• Monitor disease processes

– Prognosis (high vs. low risk patients)

– Monitoring effect of therapeutic interventions

Diagnostic & pathogenic markers

The evolving clinical definition of MS

1. Schumacher, et al. Problems of Experimental Trials of Therapy in Multiple Sclerosis: Report

by the Panel on the Evaluation of Experimental Trials of Therapy in Multiple Sclerosis. Ann N

Y Acad Sci 1965;122:552-68.

2. Poser, et al. New diagnostic criteria for multiple sclerosis: guidelines for research protocols.

Ann Neurol 1983;13:227-31.

3. McDonald, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from

the International Panel on the diagnosis of multiple sclerosis. Ann Neurol 2001;50:121-7.

4. Polman, et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the "McDonald

Criteria". Ann Neurol 2005;58:840-6.

5. Polman, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald

criteria. Ann Neurol. 2011;69:292-302.

Will Rogers Phenomenon in Multiple Sclerosis

1879 - 1935

“When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states.”

Will Rogers Phenomenon in Multiple Sclerosis

Sormani et al. Ann Neurol 2008;64:428–433.

Poser

McDonald

Intrathecal synthesis of IgG

Images courtesy of Alastair Compston and Ed Thompson.

Kabat et al. J Clin Invest. 1942 Sep;21(5):571-7.

Carl Lange – Colloidal Gold Curve

Isoelectric focusing with immunfixation

Diagnostic criteria for Primary Progressive MS

Polman et al. Ann Neurol 2005;58:840-6.

Accumulation of disability in PPMS: stratified by intrathecal IgG abnormalities

Proportion Progressing as Percent

Epoch CSF- CSF+

6 mo 7.3 9.8

12 mo 15.0 20.4

18 mo 22.8 28.1

24 mo 25.4 34.3

Years to Progression

2.43 2.26

Based on data from a second meeting of the DSMB and assume no therapeutic effect

0 1 2 3 Years

0.0

0.2

0.4

0.6

0.8

1.0

Pro

po

rtio

n P

rogr

essi

ng

Positive Negative

CSF

Slide courtesy of Jerry Wolinsky

P =0.03

Dobson R, et al. J Neurol Neurosurg Psychiatry 2013;0:1–6.

What constitutes a useful diagnostic test or set of criteria?

TARGET DISORDER

PRESENT ABSENT

DIAGNOSTIC

TEST RESULT

+ a b a + b

- c d c + d

a + c b + d a + b + c + d

From these we determine the sensitivity and specificity as follows:

SENSITIVITY = a/(a+c) > 80%

SPECIFICITY = d/(b+d) > 80%

Neurobiol Aging 1998; 19:109-116.

A clinico-pathoanatomical study of multiple sclerosis diagnosis

SENSITIVITY = True+ve /(True+ve + False-ve)

Eye Department, Hvidovre Hospital, Denmark.

• Neuropathological examination of 518 consecutive patients with clinically definite MS revealed a correct diagnosis in 485 cases (94%).

• Clinical diagnosis had been established by a neurologist in all cases.

• Erroneous diagnosis included a variety of other neurological disorders.

• Also investigated was a randomly selected series of 33 patients with a clinical diagnosis of probable MS:

– post mortem confirmation of MS was obtained in circa 66%.

– The remainder the error pattern was similar to the above.

Engell T. Acta Neurol Scand. 1988 Jul;78(1):39-44.

Kleinschmidt-DeMasters,et al. N Engl J Med. 2005 Jul 28;353(4):369-74.

PML complicating treatment with natalizumab and IFNb-1a for MS

A clinico-pathoanatomical study of multiple sclerosis diagnosis

SPECIFICITY = True-ve /(True-ve + False+ve) ?

~25% of cases of MS are undiagnosed in life (asymptomatic or benign cases)

Engell T. Acta Neurol Scand. 1989 May;79(5):428-30.

Other diagnoses - MRI white matter changes

• ADEM

• Ageing

• Behcet’s syndrome

• Cerebrovascular disease

• Decompression sickness

• Fat embolism

• HIV encephalitis

• HTLV1-associated myelopathy

• Hydrocephalus

• irradiation

• Leukodystrophies

• Migraine

• Mitochondrial encephalopathy

• MND

• Neurosarcoidosis

• Phenylketonuria

• PML

• SSPE

• SLE/APL

• Trauma

Miller DH. (1997)

Lennon et al. Lancet 2004;364:2106-12.

NMO

Pharmacovigilance markers

Take special care with Interferon-beta-1b: If you might have a disorder of the immune system in which abnormal proteins are found in the blood (monoclonal gammopathy), you must check this with your doctor before you use interferon beta-1b. Patients who have the rare condition known as monoclonal gammopathy may develop problems with their small blood vessels (capillaries) leading to shock (collapse) which can be fatal, when they use medicines like interferon-beta-1b. See also 4. Possible side effects.

“There are known knowns; there are things we know that we know. There are known unknowns; that is to say, there are things that we now know we don't know. But there are also unknown unknowns – there are things we do not know we don't know.”

United States Secretary of Defense, Donald Rumsfeld

Salzman C. N Engl J Med 1990 20; 323:827-9.

Natalizumab

Progressive multifocal leukoencephalopathy (PML)

Kleinschmidt-DeMasters,et al. N Engl J Med. 2005 Jul 28;353(4):369-74.

359 cases -30th April 2013 83 (23%) died 276 (77%) alive

Mild disability – 10% Moderate disability – 50% Severe disability – 40%

5% NAbs – infusion reactions

Natalizumab PML risk stratification tool

Anti-JC virus antibody status

Negative Positive

Prior immunosuppressant use

Natalizumab treatment

>2 Years

Natalizumab treatment

>2 Years

No Yes

No Yes No Yes

Lowest Highest Relative PML Risk

< 1 in 10,000 1 in 94 1 in 256 1 in 668 1 in 1887

Mitoxantrone

Azathioprine

Methotrexate

Cyclophosphamide

Mycophenolate

Cladribine

Rituximab

Etc.

Neurology 2012;78(Suppl.): [S41.006]

Predicting autoimmunity following treatment of MS with alemtuzumab

• 30% of alemtuzumab-treated pts develop autoimmune side-effects (primarily thyroid disease and idiopathic thrombocytopenia)

• Aim: To define predictive factors for autoimmune side-effects

• Sera of 141 pts screened at baseline for 8 different cytokines/chemokines

A combined IL-21/IL-7 test on pre-treatment serum may be useful to identify patients at low risk of developing autoimmunity following treatment with alemtuzumab

Jones JL, et al. ECTRIMS 2011, Amsterdam. P1009

Sensitivity NPV Specificity PPV

IL-21 alone 81 84 70 66

IL-7 alone 76 76 54 54

CCL21 alone 63 65 49 47

IL-21 or IL-7 98 97 41 55

IL-21 OR IL-7 OR CCL21

98 91 12 45

Given that pts may elect to receive treatment based

on results of this test – most weight given to

minimizing false negative results. Combining IL-21

and IL-7 into a single test offers improved test

accuracy over IL-21 alone. CCL21 did not improve

test accuracy

0

10

20

30

40

IL-7

Autoimmunity No autoimmunity

0

500

1000

1500

IL-2

1

1.0

Se

nsit

ivit

y

0.8

0.6

0.4

0.2

0.0 0.0 0.2 0.4 0.6 0.8 1.0

1.0

Se

nsit

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y

0.8

0.6

0.4

0.2

0.0 0.0 0.2 0.4 0.6 0.8 1.0

1-Specificity

IL-21 and IL-7 levels in sera

of pts who did or did not

develop autoimmunity

Receiver operating

characteristic (ROC) curves

Anti-natalizumab Antibodies

Number of Patients at Risk

Placebo

Antibody Negative

Transiently Positive

Persistently Positive

315

568

20

37

296

550

19

32

283

538

18

26

264

526

16

25

248

506

16

24

240

487

16

22

229

480

15

22

216

470

14

19

208

460

14

16

200

449

14

15

Weeks

0.0

0.1

0.2

0.3

0.4

0.5

0 12 24 36 48 60 72 84 96 108 120

29%

Placebo

17%

Antibody Negative

17%

Transiently Antibody Positive

34%Persistently Antibody Positive

Cu

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Pro

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Dis

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Pro

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(E

DS

S) *,†

*p ≤0.05 vs. antibody-negative patients†p=0.66 vs. placebo

Number of Patients at Risk

Placebo

Antibody Negative

Transiently Positive

Persistently Positive

315

568

20

37

296

550

19

32

283

538

18

26

264

526

16

25

248

506

16

24

240

487

16

22

229

480

15

22

216

470

14

19

208

460

14

16

200

449

14

15

Weeks

0.0

0.1

0.2

0.3

0.4

0.5

0 12 24 36 48 60 72 84 96 108 120

29%

Placebo

17%

Antibody Negative

17%

Transiently Antibody Positive

34%Persistently Antibody Positive

Cu

mu

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ve

Pro

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us

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Dis

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y

Pro

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ion

(E

DS

S) *,†

*p ≤0.05 vs. antibody-negative patients†p=0.66 vs. placebo

0.73

0.220.16

0.48*

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Ad

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ted

An

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Ra

te (

95

% C

I)

Placebo

(n=315)

Antibody Negative

(n=568)

Transiently

Antibody Positive

( n=20)

Persistently

Antibody Positive

(n=37)

*p=0.009 vs. antibody-negative patients

0.73

0.220.16

0.48*

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Ad

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An

nu

ali

ze

d R

ela

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Ra

te (

95

% C

I)

Placebo

(n=315)

Antibody Negative

(n=568)

Transiently

Antibody Positive

( n=20)

Persistently

Antibody Positive

(n=37)

*p=0.009 vs. antibody-negative patients

Calabresi et al, Neurol 2007

Impact of anti-natalizumab antibodies on . . . . .

Annualized relapse rate Progressive disability

Natalizumab infusion reactions

• Acute hypersensitivity reactions are well-recognized

• Generalized urticaria, dizziness, fever, rash, rigors, pruritus, nausea, flushing, dyspnea, chest pain

• Onset generally during or within 1 hour of second infusion

• Incidence ~4%

• severe anaphylactic/anaphylactoid reactions <1%

• Most reactions are associated with anti-natalizumab antibodies

• Treatment:

• immediate and permanent cessation of natalizumab

• antihistamines

Rudick et al, NEJM 2006

Monitoring effect of therapeutic interventions

Reduced efficacy due to NAbs – systematic review

Farrell & Giovannoni, Multiple Sclerosis 2007; 13: 567-577.

Clinical importance of neutralising antibodies against interferon beta in patients with relapsing-remitting multiple sclerosis

Sorensen et al. Lancet 2003; 362: 1184–91.

Mean change in EDSS

Malluci et al. Neurology 2004.

Predictive markers for response to interferon therapy in patients with multiple sclerosis

Malucchi et al. Neurology 2008;70:1119–1127.

Jacob Elkins, James Sheridan, Lakshmi Amaravadi, Katherine Riester, Gilmore O’Neill

Neurology 2012;78(Suppl.): S31.004

Prognostic markers

Scandinavian Simvastatin Survival Study (4S)

Reprinted from The Lancet, Vol. 344, Scandinavian Simvastatin Survival Study Group, 1383-1389

0.95

0.90

0.85

0.80

Proportion Alive

Years Since Randomization

0 1 2 3 4 5 6

Simvastatin

Placebo

Log rank: p=0.0003

0.00

1.00

Can body fluid biomarkers compete with MRI?

Petzold, J Neurol Sci. 2005 Jun 15;233(1-2):183-98.

Petzold et al. J Neurol Neurosurg Psychiatry. 2005 Feb;76(2):206-11.

Spinal fluid neurofilament levels

Gunnarsson et al. Ann Neurol 2010; Epub.

CSF NFL

Scientific Process

The Scientific Process of Biomarker Development

Phase 0 – Assay Development

source of reagents, sensitive, specific

reliable, reproducible

low coefficients of variation

quality control

Hypothesis & study objectives

Phase 1 – Animal, in vitro models cross-sectional “proof of concept” studies

Target: population vs. patients

Single vs. panel of biomarkers

Patient groups vs. normals

Patient group vs. disease controls

Phase 2 – Longitudinal study

Study patient characteristics – age, disease type, etc.

Method of case selection – retrospective, prospective, stratification, matching (age, sex, etc.)

Treatment received - randomised

Phase 3 – Independent longitudinal studies

Multi-centre studies

Phase 4 - FDA & EMEA licensing

Surrogate end-point

Biobanking

Reporting

Phase 3 – Longitudinal study

Multi-biomarker strategy – soluble biomarkers incorporated with imaging markers.

Study duration – median follow-up time

Clinical and data end-points defined

Data and statistical analysis – define models used, handling of missing data, etc.

Internal Validation

External Validation

Body fluid biomarkers in clinical practice

• Diagnostic

• CSF OCBs

• Baseline Risk

• Serum protein electrophoresis

• JCV serology

• VZV serology

• TB Screening

• Monitoring

• Bloods: FBC, LFTs, U&E, TFTs & beta-HCG

• Urine (rbcs)

• Serology

• NABs IFN-beta

• NABs Natalizumab

• JCV serology

• CSF

• JCV DNA

• NFL