Re-use of drug already marketed for ALS.

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Is it possible that a medication treating congestive heart failure can improve the breathing of people with ALS? Or that a drug used to treat cancer could reduce motor neuron inflammation and possibly slow the progression of the disease?

The reuse of drugs is not a new idea. Many drugs have found a new function - for example tamoxifen, originally developed to treat breast cancer, is now used in the treatment of bipolar disorder.

So, how can a medicine that treats a disease, act for another disease?

Obviously, once a drug enters the body, we have little control over its delivery. Although it can be designed to treat, for example, kidney cells, it also travels and interacts in other places. It is these "non-targeted" effects that cause the side effects of drugs. Sometimes, however, this disruption can have positive effects and it is these beneficial results that drug reuse attempts to exploit.

However, we can not take an approved medicine and give it to people with another disease simply because we think it could work for them. Pre-clinical tests and clinical trials are still needed. A safe dose must be established for the new therapeutic target, a certain degree of efficacy must be established, and we need to understand the benefits and risks before the drug can be made available as a new treatment.

MIROCALS - IL-2: From cancer treatment to motor neuron protection

This trial tests interleukin-2 (IL-2), a drug already used to treat some forms of cancer. IL-2 is naturally produced by the body. Its main role is to promote the production of regulatory T cells (or Tregs) - a part of the immune system that is thought to play a role in protecting nerve cells from damage. IL-2 can increase blood levels of Treg and could protect motor neurons in ALS, slowing the progression of the disease.

Studies have already identified the lowest dose of IL-2 that still triggers an increase in Treg without serious side effects.

The goal of this phase 2 trial is to evaluate the safety and efficacy of IL-2 and to confirm that altering the immune response by increasing the Treg rate will slow down the progression of ALS. The study will recruit 216 participants and the results are expected in autumn 2021.

TUDCA - a treatment for liver disease that could protect motor neurons from programmed cell death

Tauroursodeoxycholic acid (TUDCA) is a bile acid. Bears contain large amounts of TUDCA in their bile.

TUDCA prevents apoptosis of cells through its inhibitory role in the transport of BAX to mitochondria.

TUDCA is a water-soluble bile salt used in the treatment of cholestasis, a liver disease in which bile acid accumulates in an unhealthy liver, damaging cells by destroying membranes and signaling cell death. TUDCA also appears to reduce the stress of the endoplasmic reticulum (ER), an organelle of the cell that facilitates the folding of proteins. By reducing the stress of the endoplasmic reticulum, TUDCA can protect against neurological damage.

The aim of this phase 3 trial is to evaluate the safety and efficacy of TUDCA as a complementary therapy to riluzole, as measured by ALSFRS-R scores, in 440 people with ALS. complete in the summer of 2022. The ALSFRS-R is used to assess and monitor functional changes in a person with ALS over time. It consists of 12 questions that deal with aspects of the person's daily life, each of which is rated by the person from 4 to 0, with 4 being "normal".

You can find out more about the TUDCA clinical trial on the TUDCA website and on clinicaltrials.gov.

Perampanel - antiepileptic drug that could prevent the toxic accumulation of TDP-43

It was the first antiepileptic drug in the class of selective noncompetitive AMPA receptor antagonists. This medication can lead to serious psychiatric and behavioral changes; it can cause homicidal or suicidal thoughts. In a mouse model of ALS, Perampanel has been shown to prevent motor neuron death by stopping the toxic accumulation of TDP-43 protein. Long-term Perampanel therapy also resulted in a visible improvement in motor function in treated mice.

The aim of this phase 2 trial is to evaluate the effect of Perampanel on disease progression (measured by ALSFRS-R) in 60 people with sporadic ALS. The results are expected for the winter of 2022. To learn more about this trial, go to clinicaltrials.gov.

Ranolazine - the drug against angina pectoris that can be neuroprotective

Used to treat angina pectoris (chest pain), ranolazine works by inhibiting the accumulation of sodium and calcium ions in cells, although the way it treats angina is not fully understood. Calcium ions play an important role in hyperexcitability when neurons "trigger" more than they would normally, causing fasciculations (muscle contractions), one of the first symptoms of ALS. Ranolazine may have a neuroprotective effect by reducing neuronal hyperexcitability, thereby slowing the progression of the disease and reducing the frequency of cramps.

The Phase 2 trial will evaluate the safety and efficacy of ranolazine in 20 people with ALS and is expected to be completed in the summer of 2019. For more information, see clinicaltrials.gov.

Pimozide - an antipsychotic that could improve muscle function

Pimozide is used in the treatment of schizophrenia and in the reduction of uncontrolled muscle tics associated with Tourette's syndrome. It works by decreasing the activity of dopamine, a neurotransmitter that sends messages between brain cells. In people with ALS, motor neuron damage results in disruption of communication between neurons and muscles at the neuromuscular junction (NMJ). Pimozide has been shown to improve communication with NMJ in mice and fish for the purpose of improving muscle function.

This phase 2 study will examine whether pimozide can help slow the progression of ALS in 100 people with the disease. The trial should be completed by the end of 2019 and you can find out more on clinicaltrials.gov.

Rapamycin - the anti-rejection drug that can prevent neurodegeneration

Used to prevent rejection of transplanted organs, rapamycin works by weakening the body's immune system to accept transplanted organs more easily. The neuron's inability to eliminate the accumulation of proteins in the cytoplasm, and an imbalanced function of the immune system that damages motor neurons by neurotoxicity rather than protecting them, are two potential influences in the development of ALS. These two mechanisms represent important therapeutic targets. In neurodegeneration models, rapamycin has been shown to suppress inflammatory neurotoxic responses caused by T cells (T cells are part of the immune system and generally protect nerve cells from damage) and aid in protein breakdown. accumulated in the cytoplasm.

The goal of this phase 2 trial, which will involve 63 people with ALS, is to obtain predictive information for a larger study. Its completion is scheduled for autumn 2019. For more information, see clinicaltrials.gov.

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