Inflammation, Immunity, and ALS, Part II: Immune-Modulating Therapies

Marlena Wosiski-Kuhn1, Miles S Lyon MS1, James Caress MD2, Carol Milligan PhD1
1
Department of Neurobiology and Anatomy, 2Department of Neurology, Wake Forest University School of Medicine,

Winston-Salem, NC
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The authors confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that

this report is consistent with those guidelines.

Dr. Caress has received past research support to perform clinical trials of many of the agents discussed in the paper.

Acknowledgements: We thank Drs. Gregory Hawkins, Michael Cartwright and Steven Shapiro for critically reading the

review. MWK is supported by the Argenta Award through WFSM. The Milligan laboratory is supported by The Hope for

Tomorrow Foundation a gift made in memory of Dr. Murray Abrams, The Blazeman Foundation for ALS, and the WFSM

Brian White ALS Foundation.

Address Correspondence to:

Carol Milligan, PhD

Department of Neurobiology and Anatomy

Wake Forest School of Medicine

Medical Center Blvd

Winston-Salem, NC 27157

Phone: 336-716-0499

Email: milligan@wakehealth.edu

Thi s article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which
may lead to differences between this version and the Version of Record. Please cite this
article as doi: 10.1002/mus.26288
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 Abstract

With the emerging popularity of immune-modulatory therapies to treat human diseases there is a need to step back

from hypotheses aimed at assessing a condition in a single-system context and instead take into account the disease

pathology as a whole. In complex diseases, such as amyotrophic lateral sclerosis (ALS), the use of these therapies to

treat patients has been largely unsuccessful and likely premature given our lack of understanding of how the immune
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system influences disease progression and initiation. Additionally, we still have an incomplete understanding of the role

of these responses in our model systems and how this may translate clinically to human patients. In the following review

we discuss pre-clinical evidence and clinical trial results for a selection of recently conducted studies in ALS. We attempt

to provide evidence-based reasoning for the failure of these trials and offer suggestions to improve the design of future

investigations.

Key Words: Amyotrophic Lateral Sclerosis, Clinical Trials, Immune Response, Neuroinflammation, Microglia, Blood Brain

Barrier

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 Introduction

At this point in our understanding of amyotrophic lateral sclerosis (ALS) pathogenesis we remain ignorant of specific

roles of immune components that may be critical to the disease. In our first review1we evaluated evidence for late-stage

activation of central immune responses, particularly microglial activation in response to degenerating motor neurons,

yet questioned whether this has any true impact on disease pathogenesis given its appearance post-cell death. It
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remains inconclusive whether monocytes and macrophages directly influence disease progression. The presence of T-

lymphocytes in spinal cords of post-mortem ALS patients and end stage ALS mice supports the role of an adaptive

immune response at later disease stages, however, earlier humoral immune responses remain largely unexplored.

Finally, the multi-functional role of HLA/MHC in the central nervous system (CNS) adds complexity to predispositions for

immune dysregulation in disease.

There is a burgeoning interest in the role of neuroinflammation and immunity in ALS. 11 of the trials mentioned in Table

S1 are from the past 3 years with 8 of these still ongoing or planned, emphasizing the growing number of these types of

interventions. The body of this review focuses on those studies with the most comprehensive information that has been

published in peer reviewed journals with an emphasis to include representative trials for various domains of the immune

system. We believe a thorough understanding of previous failed therapies may inform future study design. Study

design, power, and mechanistic rationale for each randomized clinical trial discussed here is presented in Supplementary

Table 1. Completed study results appear in Supplementary Table 2.

Innate Immunity

We start by discussing trials where therapies primarily modulated innate immunity, specifically monocyte-derived cell

populations. The first two of these therapies were not primarily meant as immune modulators but each is also reported

to have such effects.

Celecoxib

Celecoxib is an FDA approved COX2 inhibitor that blocks prostaglandin synthesis. Prostaglandins stimulate astrocytic

glutamate release2, 3 and, with glutamate excitotoxicity a known pathological event in ALS, COX2 seems a logical

therapeutic target. Prostaglandin E2 (PGE2) has been accepted as a biomarker for COX2 activity in tumorigenic tissue4.

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 However, COX2 and prostaglandin products are also crucial homeostatic regulators of acute and chronic immune and

inflammatory responses, especially as related to macrophage polarization5.

Pre-clinical Data

Animal:

The majority of preclinical data supporting the use of COX2 inhibitors in ALS came from work in the mSOD1G93A mouse
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model6. Protein signatures for COX2 and PGE2, but not COX1, first accumulate in ventral spinal cord starting at p90 and

peak at end stage (reference 1: first figure); COX2 protein is localized mainly within ventral horn neurons surrounding

reactive astrocytes7. If associated with restraining astrocyte activation, which can be toxic to motor neurons, COX2

inhibition may be protective.

Three studies tested potential significance of COX2 inhibition on disease progression in the SOD1 mouse model. Two

studies had mixed results of unknown relevance because of powering issues; both showed spinal cord PGE2 inhibition,

indicating that the agent was effective, but lack of significant effect on disease onset or survival suggested no influence

on pathology11, 12. However, in the only of these studies appropriately powered according to guidelines for testing

treatment efficacy in the SOD1 mouse,8oral administration of Celecoxib beginning at p28 (see reference 1: first figure)

significantly reduced spinal cord levels of PGE2 and increased survival by 28 days9.

Patient:

Postmortem ALS spinal cord tissue from 5 patients showed elevated PGE2 compared to neurological controls without

spinal cord pathologies7. Another study in 9 ALS patients showed elevated PGE2 in the cerebrospinal fluid (CSF)12 but it is

apparent from the individual data that there was a wide range of values with nearly half of ALS subjects falling into the

control range. Unlike the mouse studies, this study found no correlation between PGE2 levels and disease duration.

Clinical Trial and Interpretations

A year-long, double-blind, placebo-controlled, randomized clinical trial (RCT) of Celecoxib13 -was conducted in which

Celecoxib was dosed at twice the recommended dose for rheumatoid arthritis (RA) and compliance was assessed by

measuring drug serum levels. The clinical trial followed PGE2 as a presumptive biomarker of COX2 activity and inhibition.

A beneficial effect was not detected; authors comment that further studies of Celecoxib at this dosage are unwarranted

and elaborate a comprehensive discussion of reasons for the trial’s failure, some of which are briefly covered here.

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 COX2 inhibitors suppress anti-inflammatory macrophage signaling, driving a pro-inflammatory environment theoretically

capable of accelerating neuromuscular junction (NMJ) denervation by attracting pro-inflammatory macrophages to

muscle14-15. Potential detrimental effects exist in the CNS as well: COX2 is reported to have a key role in resolution of

neuroinflammation by causing death of over-active microglia and, in animal models, Celecoxib prevents this activity16.

This opens the possibility that any CNS-positive effects from Celecoxib’s anti-excitotoxicity mechanism could be masked
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by disrupted homeostatic control of hyperactive microglia.

In preclinical animal trials, treatment started relatively early in the disease process. However, some patients in the

clinical trial began treatment up to 5 years after symptom onset. As in many ALS human trials, variability in this patient

population confounds detecting potential therapeutic effects in a specific subset. As discussed1, it remains unclear if

immune processes are involved in ALS pathology. As such, it is critical that future-patients selected inflammatory-

modulating trials be screened for active inflammation.

This study attempted to monitor a biomarker of drug efficacy: PGE2 protein in CSF. Human studies have supported use

of serum PGE2 as a biomarker of COX2-inhibitor-produced analgesia, and tissue levels of PGE2 respond to COX2-inibitors

in the SOD1 mouse17 but issues remain: in the SOD1 mouse, COX1, not COX2, is the primary source of PGE2. It has even

been postulated that neurodegeneration in this model occurs independently of PGE218. In the clinical trial, overall CSF

PGE2 levels did not decline with treatment and, even in a post-hoc subanalysis of treated patients who did show

decreased PGE2 levels compared to those who didn’t, there was no difference in outcome measures. These could be

due to a variety of issues (discussed in depth in reference 12) including the small number of patients willing to do a

second lumbar puncture (LP), that CSF levels of PGE2 don’t necessarily reflect COX2 activity in the CNS (as preclinical

work looked mainly at spinal cord tissue itself) or that the levels weren’t elevated at baseline.

It appears that COX2 activity is necessary to maintain blood brain barrier (BBB) integrity during innate immune

activation19. Inhibition of COX2 may therefore have an unintentional detrimental effect of increasing BBB permeability.

The BBB permeability and its significance in human ALS has yet to be reliably characterized, with existing observations

limited and inconclusive20-23.

Finally, given the preclinical evidence of when (endstage in mouse, postmortem in human; both after substantial

denervation) and where (primarily neuronal) COX2 is observed, it is possible that COX2 does not have a role in disease

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 onset or progression but rather simply reflects a reaction to the neuronal death and surrounding gliosis, itself triggered

by degeneration. While there was extension of survival in the mouse model, no investigation into inhibition or delay of

specific pathological events (e.g., NMJ denervation, glial activation, or motor neuron survival) were reported.

Minocycline

Minocycline is an FDA approved, broad spectrum tetracycline antibiotic typically prescribed for skin infections24,26 . (.
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Oral minocycline is known to cross the BBB to reach active CSF concentrations25.

Pre-clinical Data

Animal:

Three separate studies using two different ALS mouse models demonstrated that starting treatment before significant

functional motor deficits prolongs survival26-28. However, none of these studies were powered to detect efficacy, likely as

they were conducted before published guidelines8.

While inhibition of cell death can extend survival, it is not sufficient to prevent earlier pathology, including

neuromuscular junction denervation and glial activation30,31. Potential effects of minocycline include not only promoting

neuronal survival but also inhibiting inflammatory activation of microglia32. However, it is not clear if these effects are

related. Further complicating interpretations, another report found administration of minocycline actually enhanced

activation of astrocytes and microglia33. Minocycline is also reported to have polarizing effects on monocyte-lineage

cells34,35, and in peripheral nerves may inhibit macrophage response to axonal injury36. Whether this is a protective or

detrimental effect in ALS is not known.

Clinical Trial and Interpretations

Two safety human trials of minocycline in ALS were completed, with a range of doses, but were not powered to look at

functional decline37,38.

A multicenter, phase III RCT of minocycline in ALS was conducted for 9 months39. The study was terminated when it was

determined that minocycline had a harmful effect on patients. Rate of decline in ALSFRS-R was 25% faster in the treated

group, mainly attributable to losses in gross motor function. Because the preclinical human studies weren’t powered for

functional decline, they could have missed the deterioration reported in the phase III trial treatment group, as post-hoc

analyses of that trial indicated that the worsened outcomes were not caused by adverse events.

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 The reported pro-survival and anti-inflammatory effects of minocycline were the basis for the rationale of this trial.

However, preclinical work in the mouse models was underpowered. As discussed above, the mechanisms of action of

this agent on neurons, microglia, astrocytes, and peripheral macrophages are not clear. Furthermore, potential

beneficial or detrimental roles of these cells in disease pathology may not be linear, with beneficial effects countered by

toxic effects.
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The BBB may also play a role in the negative results of this trial. A recent review on BBB-driven pharmacoresistance in

ALS therapies highlights how treatments which are substrates for multidrug efflux transporters (eg P-gp), may have

decreased therapeutic benefit in diseases where P-gp expression is increased at the BBB, such as ALS40. Minocycline is a

substrate for P-gp, creating the possibility that it was effectively pumped out of the CNS in all or a subset of patients

with higher expression of P-gp. This is especially relevant as the proposed therapeutic mechanism of action of

Minocycline requires CNS penetration and the peripheral effect of the drug could have been to limit a potentially helpful

macrophage response to peripheral nerve injury36.

Glatiramer Acetate

Two separate trials have been conducted to evaluate the effect of glatiramer acetate on ALS. GA treats multiple sclerosis

of the relapsing-remitting type (RRMS) to reduce frequency of flare-ups. The majority of information on the mechanism

of action comes from MS-centric studies.41-43

Pre-clinical Data

Preclinical work in ALS animal models reported inconsistent success of GA, with results varying by animal strain,

background, gender and co-administration of Freund’s adjuvant44-46. The vast majority of experimental evidence for the

actions of GA came from human MS patients and animal models (experimental autoimmune encephalitis). However, the

assumption of equivalent responses to GA in human MS and ALS patients may be problematic. Studies with cultured T

lymphocytes from treated animals show inverse Th1 and Th2 cytokine responses: with treatment, these cytokines (IFNγ

and IL-4) were decreased in ALS yet increased in MS, indicating disease-specific effects of GA on T-cell differentiation44,47.

Clinical Trials and Interpretations

A phase 2 RCT compared the effect of GA-exposed T-cell proliferation between ALS patients treated daily, biweekly and

untreated controls. The authors theorized that less frequent dosing regimens would favor a predominately protective

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 Th2 response47. After 6 months, the daily injection group was more similar to controls whereas there was an inverse

pattern in the biweekly group48. The authors point out that this could have been because the less frequent dosing group

had induced more Treg cells. However, while this study followed clinical outcomes as a safety measure, information was

not reported on the functional decline of patients.

The second study was a year-long, double-blinded, multicenter RCT with significant power to detect clinical
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progression49. While the results of this study were negative for all outcomes followed, neutralizing antibodies and

pharmacodynamic markers to predict the activity of GAs proposed immunomodulatory action were not monitored, and

thus it cannot be assumed that the lack of functional improvement reflected a failed physiological mechanism.

The authors point out that lack of a clear marker for either transport through the BBB of immunocompetent cells or

presence of CNS action is a major hurdle in assessing effectiveness as penetration of GA-responsive T-cells through the

BBB is a key factor in the biological activity of GA treatment in MS. In ALS, the involvement of T-cells in disease onset and

progression is unclear (see reference 1). Further, there may be differences between BBB disruption in these two

diseases and it is possible that these GA-responsive T-cells were unable to reach the CNS in ALS patients.

It is also of note that many drugs targeted at the immune system have a modulatory effect at lower doses but are purely

immunosuppressive at higher doses. The dose used here is twice the commonly studied and recommended dose of GA

for MS. Predominantly immunosuppressive treatments, such as total lymphoid irradiation or high-dose pulse

cyclophosphamide, were reported to be ineffective in slowing the progression of ALS50,51.

NP001

NP001 is a pH-adjusted, stabilized form of a sodium chlorite drug previously used for post-radiation syndrome in AIDS.52

Pre-clinical Data

A non-peer reviewed study in SOD1 mice, described in a press release53, is the only apparent preclinical animal model

evidence.

Clinical Trials and Interpretations

Because there was an effect of NP001 on extending lifespan of the SOD1 mouse when administered before overt

functional impairment (model/survival specifics unknown)53, a phase 1, placebo-controlled, single ascending dose safety

and tolerability trial was carried out in 32 patients (0.2, 0.8, 1.6, 3.2 mg/kg IV)54. Before initiating the phase 1 study,

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 researchers isolated and characterized monocytes from ALS patient blood in terms of expression of CD16 and HLA-DR, to

define potential biomarkers that changed with NP001 treatment54. CD14+CD16+HLADR+ monocytes account for

approximately 10% of all monocytes in healthy human blood55 and may represent the most mature of the circulating

monocyte population. Many studies, in vivo and in vitro, have shown CD16 (FcγIII receptor) as an antigen associated with

expression patterns characteristic of tissue macrophages56-58. The CD16+CD14+HLADR+ peripheral blood mononuclear
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cells (PBMCs) characteristically release little or no anti-inflammatory IL-10 but are a strong source of proinflammatory

TNFα in response to LPS and show higher potency towards antigen presentation55,58. This particular subset has been

observed as altered in autoimmune disorders; it is expanded and preferentially activated in MS, but reduced and

dysfunctional in systemic lupus erythematous59,60.

Monocyte markers are logical investigative biomarkers for disease activity given the evidence for macrophage activation

in ALS described in part 1 of this review1, and that, in the animal model, cells expressing the mouse equivalent of CD16

accumulate within the spinal cord as disease progresses. These markers specifically relate to alterations of blood

monocyte populations that occur with disease progression. Two separate studies using peripheral blood from a total of

80 sALS patients exhibited elevated CD14+CD16+ monocytes characterized by high HLA-DR and low CCR2 compared to

healthy and neurological disease controls (Alzheimer’s disease + age-related macular degeneration)61,62. CCR2 is

expressed on the surface of monocytes and mediates their chemotaxis in response to MCP-163. Increased HLA-DR could

predispose cells to be self-reactive, while the low responsiveness to chemotaxis through CCR2 may inhibit beneficial

responses like clearing cellular debris.

Miller and colleagues saw that, in agreement with this previous data, at baseline, blood monocytes from ALS study

subjects showed increased monocyte activation (CD14+HLADR+). For the mature macrophage subset

CD14+CD16+HLADR+, CD16 levels were positively related to the estimated rate of ALS progression54. 24-hours post

dosing, monocyte HLA-DR expression had decreased in all patients that had shown an elevated baseline; the magnitude

of reduction positively correlated only with the level of baseline elevation. In contrast, there was an observed dose-

dependent change in monocyte CD16 expression not correlated with baseline expression.

Because there was no dose-dependence in HLA-DR expression reduction, authors speculate that HLA-DR monocyte

expression indicates systemic inflammation and, therefore, the minimally effective dose (0.8 mg/kg) that reduced

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 monocyte HLA-DR is reflective of a global anti-inflammatory response. However, NP001 appeared to have an immune-

modulatory effect at higher doses (1.6, 3.2 mg/kg), effectively reducing CD16+CD14+HLADR+ monocyte activation,

potentially affecting monocyte migration from blood to tissue. Again, this illustrates the importance of considering

dosage when attempting to suppress or modulate immune responses.

The follow-up, phase 2, double-blind, multi-center, RCT of NP001 utilized the higher, hypothetically immune-
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modulatory, doses for a 6 month treatment period64. This study evaluated plasma levels of many inflammatory

molecules (Table S1), but did not attempt to replicate the previous study’s findings for peripheral monocyte HLA-DR or

CD16 with a prolonged administration. There were non-significant effects of a trend towards a slower decline, but the

magnitude of this decline (<20%) was below the study power, potentially indicating a need for future studies powered to

detect a smaller effect.

The post-hoc analysis on subjects from this study suggested “responders” to this therapy, i.e. those patients whose

ALSFRS-R did not change from baseline during the treatment period, of which there were twice as many in the

treatment (25%) than either control group (11%). At baseline, the responders had elevated interleukin-18, a

proinflammatory factor produced by M1 macrophages, and were positive for LPS, a potent M1 phenotype inducer.

Notably, over the study period in the placebo group, patients either became LPS+ or showed increasing levels of LPS

regardless of clinically-measurable disease progression. These results suggest that LPS accumulation in ALS patients may

be part of disease progression and a trigger for further inflammatory responses that may exacerbate disease

progression.

The presence of circulating LPS in ALS moreso than other neurological diseases has been repeatedly reported but it

remains unclear if this represents part of disease pathogenesis or is related to underlying infectious processes occurring

in this often fragile population65,66. LPS may be produced by the aerobic or facultatively anaerobic gram-negative

bacteria that inhabit the mucosal surfaces of the respiratory tract and gut67 and in the case of a “leaky gut” (an impaired

mucosal barrier) this LPS will leak into systemic circulation68. The SOD1 mouse is reported to have an impaired gut

mucosal barrier and this phenomenon has been observed in humans in other neurodegenerative diseases, although the

topic is still highly debated69,70. These observations of circulating LPS in ALS patients merit further exploration, especially

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 to determine if macrophage polarization is directly a result of these circulating levels or if they are reflective of impaired

mucosal barriers or another separate pathogenic process as recent work with IL6 and dendritic cells may suggest71.

The authors mention what they deem might have been a dose-response effect: twice as many patients on the high dose

(25%) didn’t progress as compared to those on the low dose (11%) or the historical control group (“HCG”, 10%).

Randomization accounted for baseline ALSFRS but another potential explanation for this finding is that the high dose
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group had the smallest percentage of subjects who completed 6 cycles (35 of 45 subjects). Those who did not complete

the study due to death or dropout were likely those with more severe progression. Within the high dose group, the

“responders” had elevated baseline IL18, IL6, IFNγ, CRP and were positive for LPS. After 6 months of treatment, 70% of

this group (6 subjects) showed decreased LPS and 80% had decreased IL18 yet there was no change in the other pro-

inflammatory biomarkers, including CRP which was later shown to correlate with severity of functional impairment in

this same population72, leaving the significance of these decreases uncertain.

Importantly, while patients were randomized for their baseline ALSFRS-R, their baseline disease progression (slope of

ALSFRS, ΔFRS, etc) was not accounted for. This leaves open a possibility that the responder group was actually a group of

patients with a slow progressing phenotype or that the responder status is associated with the physiological state of an

“ALS plateau” rather than any effect due to treatment. Even with randomization, only a longitudinal observational study

would be able to answer the question of an immunological signature for an ALS plateau.

Adaptive Immunity

We now move on to discuss studies that attempted to modulate adaptive immune response, chiefly that of T-cells. Total

lymphoid irradiation (TLI), which selectively targets lymphoid tissue, is an attempt at abolishing circulating lymphocytes

for a long period of time. These cells have been observed in the spinal cord of ALS patients at autopsy and are known to

induce pro-inflammatory microglial phenotype(s)73. A prospective, double-blind, RCT treated ALS patients with TLI or

sham radiation then followed their disease for two years50. There was a maintained reduction in circulating CD3+ and

CD4+ Th cells. Interestingly, in TLI-treated patients, the number of cytotoxic CD8+ (Tc) cells increased significantly, and

the number of B-cells increased to three times their baseline levels after treatment. Nonetheless, there was no

difference in functional decline or survival of irradiated patients. A post-hoc analysis combining the leukocyte subset

analyses and immunity challenges (see Table S1) further showed that more effective immunosuppression by these

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 measures did not correlate with a more favorable disease course. Together, these results suggest that circulating

lymphocytes do not play a role in mediating disease progression.

Fingolimod

Fingolimod phosphate was the first approved oral therapy for MS where it is proposed to work by two mechanisms:

indirectly it reduces effector lymphocytes exiting secondary lymph organs, limiting migration of pathogenic T-cells into
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the CNS while also increasing the proportion of circulating, protective, Treg cells – it causes population redistribution

rather than complete depletion of lymphocytes74. Also, after systemic administration, this lipophilic drug readily enters

the CNS where endogenous sphingosine kinases generate fingolimod’s active form which promotes the neuroprotective

effects of microglia, downregulating proinflammatory cytokine production, just as how it downregulates peripheral

proinflammatory cytokines from macrophages75,76. Theoretically, downregulation of these proinflammatory cytokines

prevents central migration of peripheral monocyte-derived cells.

Pre-clinical Data

Animal:

Administration of fingolimod to the late-stage SOD1 mouse showed prolonged survival by 15 days but did not improve

performance on the rotorod or prevent weight loss77. These results must be considered cautiously because this study

was not powered for efficacy8.

Clinical Trials and Interpretations

Recently, results were published of a phase IIA RCT treating ALS patients for one month with the dose of fingolimod

approved by the FDA for multiple sclerosis 119. While not powered for efficacy, this study sought to determine if

circulating lymphocytes and their subsets could serve as a pharmacodynamic marker of target engagement. As

expected, total lymphocyte count decreased and the decline in CD4+:CD8+ ratio suggested that CD4+ cells were more

effectively sequestered. The authors note that given the rapid and robust decrease in the circulating lymphocytes, the

given dose may be too high for immune modulation, instead completely suppressing responses. Indeed, the FDA NDA

review of fingolimod determined that the 0.5mg qd dose was higher than the observed half-minimal inhibitory

concentration (IC50: 0.345)78.

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 The preferential sequestration of CD4+ T-cells may prove especially beneficial in ALS as, unlike in MS, the T cell infiltrate

observed in ALS post mortem human spinal cord is primarily CD4+79. However, because Treg cells are part of the CD4+

subset it may be that these infiltrates are representative of an attempted protective response rather than a detrimental

pathogenic mechanism. Indeed, with treatment, PBMC expression of Fox3p was reduced. Given that lower levels of

Foxp3 correlates with more rapid decline and patients with higher Treg (CD4+/CD17+) cells have slower progression80
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preferential sequestration of CD4+ may be detrimental. The authors agreed that absolute reduction in Foxp3 in the

absence of other immune-related gene changes would be a cause for caution and that quantification of the specific Treg

subset could be included in future studies. A dose response study may be able to determine the ideal dose for immune

modulation or the drug may have to be titrated on an individual basis to Fox3p or CD4+/CD17+ (Treg) levels. Future,

larger studies could also consider monitoring circulating lymphocyte subsets within the CNS.

Cytokine Responses

As messengers that coordinate the innate and adaptive responses, proinflammatory cytokines are well suited to

modulate inflammation and thus have been pursued as potential drug targets for treatment of ALS. As mentioned1,

interactions between T-cells and peripheral macrophages and the ability of these macrophages to bias the T cell

response could be a more effective target in ALS than attempting to modulate the T cell response itself.

Anakinra

Interleukin-1β (IL1β) is an important mediator of inflammation, but is also involved in cell proliferation, differentiation,

and apoptosis. Monocyte-lineage cells can produce a pro-protein that is cleaved by caspase-1 into active IL1β in

response to various danger signals, including nonmicrobial ones from the inflammasome81. Both mutant SOD1 and TDP-

43 are reported to activate microglia through the inflammasome, upregulating IL1β82,83. Anakinra is a recombinant

human IL1R antagonist protein that limits the effects of IL1β and is FDA-approved to treat RA.

Pre-clinical Data

Conflicting evidence exists for the role of IL1β in ALS, as a response to or an augmentor of neurodegeneration, and

preclinical studies of anakinra itself in the disease are very limited84,85. Administration of anakinra to the SOD1 mouse

resulted in only a 6 day increase in survival and transgenic deficiency of IL1β a 10 day increase82. While this study was

adequately powered for efficacy, results suggest only minimal improvement. Relative reduction in microgliosis and

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 astrogliosis in the spinal cord of treated animals at end stage suggest the agent did reach the CNS. Together this and

other trials suggest IL1B has a limited role in disease progression in the mouse model86.

Clinical Trials and Interpretations

For a human trial of anakinra in ALS, researchers chose to treat patients with dominant or exclusive lower MN

degeneration for one year with the hypothesis that inflammation at peripheral nerve fibers is more accessible to the
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drug87. There were no differences in clinical outcomes between treated patients and an HCG. The utility of HCGs to

assess treatment efficacy in clinical trials depends greatly on the similarity between the current control arm and the

historical data88. However, this study did not have a current control arm, leaving open the possibility that the HCG was

not properly matched, especially given the discrepancies between gender in the treatment and HC groups (6% v 39%

female, respectively). Regardless, the study was not powered for efficacy but evaluated the change in serum cytokines

and inflammatory markers.

Unlike some previously discussed studies, here the chosen markers indicate modulation of the inflammatory response

rather than overt immune suppression, consistent with the multifactorial effects of interleukins. The two acute phase

reactants measured showed opposing results: fibrinogen was persistently decreased throughout the trial whereas CRP

levels rose with time. Mean levels of IL6 and TNFα had trended down by 24 weeks but then increased, along with

neutrophil number, for the remainder of the study. The authors suggest that this is suggestive of secondary

ineffectiveness in the latter half of the study, potentially due to the antibodies generated by 94% of subjects against

anakinra.

It remains unknown if treatment with anakinra will be effective in ALS patients. Anakinra will cross the BBB and reach

effective concentrations in mice89 and humans with subarachnoid hemorrhage90 but CSF levels were not monitored in

this study so it remains unclear if the drug had any central effects. Because the animal study with an IL1R antagonist

demonstrated reduced gliosis in the CNS of treated animals85 it may be worth examining the central effects of blocking

IL1β in humans with PBR-28 PET scans. If CNS IL1 and microglial activation contribute to disease progression,

administration of CNS Anakinra may be effective at delaying disease progression. Carefully controlled and monitored

studies are necessary to further determine potential therapeutic value.

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 Tocilizumab

Interleukin-6 (IL6) is a key regulator of inflammation and has repeatedly been reported as elevated in the serum and CSF

of ALS patients91-94. IL6 expression increases in pathological events that occur in all ALS patients: muscle atrophy and

compromised respiratory function95-97. IL6 regulates resting T-cells by controlling proliferation and resistance to

apoptosis. Tocilizumab is a humanized monoclonal antibody against the IL6 receptor and is FDA-approved for the
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treatment of RA.

Pre-RCT Data and Ongoing Clinical Trial

Two small human studies (≤10 subjects) demonstrated a potential utility of blocking IL6 with the drug, Tocilizumab, in a

subset of responsive patients91,98. As a result, the ongoing phase II RCT treating ALS patients with tocilizumab is the first

ALS clinical trial using immune or inflammatory modulatory therapies that attempted to recruit a defined study

population of “responders” based on preclinical evidence.

Interpretations:

Although a well-defined inflammatory modulator, the ultimate effect of IL6 is dependent on the receptor and cell type

activated. In “classical” signaling, IL6 activates limited cell types via the membrane bound IL6 receptor (mIL6R). Through

ectodomain shedding of the soluble receptor, sIL6R, “trans-signaling” dramatically increases the number of IL6 target

cells99. Trans-signaling promotes a proinflammatory milieu of Th17 effector cells where CD4+ T-cells are activated to

produce Th2 cytokines while inducible, anti-inflammatory Treg responses are suppressed99-103. Indeed, IL6 trans-signaling

is considered the pathologically relevant IL6 mechanism in disease104. Specific blockade of sIL6R trans-signaling relieves

multiple human inflammatory diseases in animal models and patients, with correlations between IL6 levels and anti-

inflammatory therapy responsiveness104-108.

The pathogenic importance of the IL6 transsignaling mechanism poses problems for preclinical animal trials attempting

to block IL6. There are species-specific shedding mechanisms of IL6R: mice and humans use ADAMS10 but only humans

use ADAMS17, with this being the major protease responsible for generation of sIL6R109. In fact, SOD1 mice treated with

MR16-1 (the tocilizumab mouse analog) showed none of the patterns in serum cytokines seen in either group of human

patients from the preclinical trials110. It is crucial to consider that the roles of IL6 transsignaling in neurodegenerative

diseases may vary in different disease stages and may depend on the ratios of IL6 to sIL6R, as this is known to influence

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 the classical and transsignaling balance111. Investigators in the current trial are addressing this by determining these

levels within study subjects (clinicaltrials.gov NCT02469896).

Conclusions

Trial-and-error clinical trials are costly in dollars, effort, and time, and disappointment is inherent in multiple failures,

both for patients and providers. The results of trials discussed here were also discouraging and at first glance may seem
Accepted article
not to have greatly advanced our understanding for specific roles of inflammation or immunity in ALS. Yet, some newer

studies appear to be hopeful in their preliminary results and, regardless, the clinical data and biological samples

collected from these trials have proved invaluable by helping identify new disease targets, biomarkers, genes, trial

designs, prediction models, co-occurring disease modifiers, and non-pharmacological interventions (for example, the

information that continues to be a result of the PROACT cohort).

Several reasons may explain the failure of these discussed and other inflammatory-modulating drugs to slow disease

progression in ALS patients, not all of which are mentioned here. First and maybe most crucial, ALS is a highly

heterogeneous disease. Preclinical testing has often been done in the SOD1 mouse model, which, while still by far the

most highly pathologically characterized model of the disease, represents the genetic cause for less than 2% of all

human ALS cases6. In humans, it is possible, even likely, that not all patients have an enhanced inflammatory component

to their disease, such as that seen in the SOD1 mouse. Thorough characterization of other ALS mouse and cellular

models with correlation to specific disease pathologies will also likely be a better predictor for treatment success than

overall organism survival. This also brings up the importance of using appropriately matched controls in human trials.

The use of historical controls as an effective placebo in ALS clinical trials remains controversial.112-115.

Also speaking to the heterogeneity of the disease, it would be advantageous to replicate results in multiple models

before treatments are moved into human populations. For example, ipsc motor neuron cell cultures will be useful for

high throughput drug screening and should be used complimentary to animal models where the specific disease

pathology can be examined in multiple tissues. This could also help limit undue influence by one positive study with

results impossible to duplicate, which is often caused by the issue of biased publication for these positive studies. Cohort

enrichment studies, such as those of the combined immunosuppressive regimen’s “Group A” and tocilizumab (Table S1),

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 can also increase cohort biological homogeneity to those subjects most likely to respond positively to the specific

treatment.

Second, we do not yet know the dynamics and nature of the interaction between the immune system and MN death.

Therefore, we do not know whether administration of immunomodulatory therapies after disease onset is too late, or

even at a time when immune activation has a protective function. For example, if microglial activation is beneficial, as
Accepted article
these activated cells remove dying neurons and support neuronal regeneration, then we would not want to hinder

them. Indeed, inhibiting microglial activation does not affect the early disease course suggesting that they are not having

a negative effect at that point in time116.Third, we haven’t characterized BBB permeability in ALS, which likely changes

with time as it does in other chronic neurodegenerative and inflammatory diseases, so often we don’t know how or if

these drugs are penetrating the CNS, or sometimes if we even want them to. Studies that lack markers of biological

activity at the target tissue and those which did not appropriately investigate ideal dosing will contribute to the

confusion of failed hypothetical mechanism vs failed delivery.

The current trial of tocilizumab begins to address various weaknesses of previous trials. By using preclinical data to

identify a potential subgroup of responders, investigators have increased the chance of finding a significant treatment

effect in a small trial. Cytokine profiling in plasma and CSF permits a comparison of how the drug and its effect may or

may not be penetrating the BBB. Similar to the use of CRP as an enrichment biomarker for the phase 2 study of NP00163,

previously classifying how PBMC pro-inflammatory gene expression changes in this group allows for assessment of

target engagement beyond traditional measures, like cytokine profiling. Finally, inclusion of PBR28 PET scans to measure

glial activation could increase significance of this smaller type of study as compared to the ALSFRS-R scores traditionally

used to assess patient response to treatment117. In fact, the ibudilast study (Table S1; NCT02714036) currently underway

is the first to be powered by PBR-28 PET results.

An issue that remains for studies where an ideal responder subgroup is identified from the general population is that

clinical features of responders (such as muscle weakness or site of onset) are not overtly different from non-responders.

This makes it impossible for clinicians to identify patients that would most likely respond to a drug without secondary

testing. We propose that future trials include a thorough, critical review of available animal and patient preclinical data,

and if this is not available, initiate studies to gather it. These data can be used to determine characterization of patient

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 inflammatory and immune profiles that will be essential to identify potential responders. Furthermore, baseline

characterization of known targets of therapeutic agents must be determined and utilized. Adjustments by basic and

clinical researchers to appropriately power and analyze their studies by published guidelines can eliminate variability.

However, even with these issues addressed, not fully understanding the immune response to ALS pre-disposes clinical

trials of immune- and/or inflammatory-modulators to failure. We must know more about the cross-talk between disease
Accepted article
pathology and immune system responses to accurately determine what aspects of the response to modify, when to do

this, and in what patients it will ultimately prove effective.

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