Update On Two AAT Clinical Trials

This is a update on two AAT (Alpha-1 Antitrypsin) clinical trials, with a little more general summary of AAT status at the end.  AAT is an anti-inflammatory/immunomodulatory drug, which the body makes naturally, and which is already FDA approved for people who have a rare condition where they don't make enough of it on their own. Using AAT to treat type-1 diabetes is based on the idea that one of AAT's effects (lowering inflammation, immune modulation, or wound healing) can cure/prevent/treat the disease.  My previous blogging on AAT is here:
http://cureresearch4type1diabetes.blogspot.com/search/label/AAT

Grifols' Phase-II AAT Clinical Trial is Unsuccessful

Grifols terminated their Phase-II AAT Clinical Trial in October 2017.  "Terminated" in the sense that they ended it earlier than expected.  Their official comment was "Wk 52 primary endpoint results would be unaffected by follow-up data so trial was discontinued prior to wk 104. No safety data was collected after wk 52."  I have unofficially been told by a participant, that they were told "it was found not to be beneficial enough".

I interpret Grifols termination statement to mean: The primary results (after 52 weeks) were bad enough, so that no matter what the results from 104 weeks, it is not worth it to them to complete the trial.

Discussion
In my opinion, it is morally wrong (and should be illegal), for a company to stop safety monitoring during a trial.  Even if the efficiency results are bad enough such that they don't care about that data any more, they still have a commitment to the patients in the trial to continue the promised safety monitoring.  The patients have already gotten the experimental treatment, so bad side effects or safety issues could still happen.

Clinical Trial Record: https://clinicaltrials.gov/ct2/show/NCT02093221

Kamada Announces Results From Their Phase-II AAT Clinical Trial

This trial had three groups: a "low dose" group, a "high dose" group, and an untreated (placebo) group.  The primary end point was change in C-peptide generation, and secondary end points included A1c, insulin dose, and safety data.  The results have not yet been published, so I'm working off of a Kamada Press release and email interactions with the team at Kamada.  The basic results are:

• No statistically significant results for the primary or secondary outcomes for the study as a whole (ie. "No significant treatment effect was observed in the overall study population").
• For one subgroup (patients aged 12 to 18), there were "close to" significant results for the primary and some secondary results.  The researchers call this a "positive trend".  The full quote is "Efficacy trend was demonstrated in the pre-determined sub-group of patients between the ages of 12 to 18, treated with the higher dose of 120mg/kg.  The positive trend was observed in this age group for all three key efficacy measures of Type-1 Diabetes".

I consider this trial unsuccessful, because the primary end point was not met.  I would not consider the subgroup data to be successful either, because none of it was statistically significant.  You can read a lot more about my definition of study success here:

https://cureresearch4type1diabetes.blogspot.com/p/recently-on-couple-of-occasions-ive.html

However, the researchers do consider it successful; successful enough to continue the work on a follow on trial aimed more specifically at the 12 to 18 year old group that had the best results here.

Discussion

Differences of Opinion on Success

So, why do I think this study is unsuccessful, while the researchers think that there is a success in there, and another clinical trial will find it?  To understand this, let's look at the three results that they consider most important:

• Better preservation of beta-cell function, as measured by less loss of C-peptide during the honeymoon (p =0.543).  
• Lower average HbA1c and more patients with A1c below 7%  (p=0.052, p=0.048, p=0.073).
• Lower insulin daily dose, for the higher dose treatment group versus placebo (p=0.086).

The standard cut off for statistical significance is p=0.05 or below.  So if you look at the numbers above, one is just in that range, three are close, and one is way out of range.  My view is out of range is out of range, and also the most important number (C-peptide) is not even close to an acceptable p-value.  C-peptide is most important for me, because it's the one that the FDA has previously said is the appropriate measure for curing type-1 diabetes.  A1c and insulin usage can be impacted by eating fewer carbs and having better control during the trial, but the C-peptide that they measured is inherent to how much insulin the body is producing itself.  The fact that they got the worst p-value there makes me profoundly nervous.

The researchers point out that they see good trends in three different measurements: insulin measurements, A1c, and C-peptide, and it is unlikely that you'd get three good trends in the same group of people, just by luck. P-value is designed (more or less) to show the chance that you got a good result by luck, rather than by the effectiveness of the treatment. P-values above 0.05 are considered too likely to be due to luck. However, in this case, the researchers point out, there are three different results, all of which are slightly above the cut-off. Even if one was due to luck, it is unlikely that all three would be due to luck. So the researchers look at all three together and view that as sufficiently unlikely to happen by luck, that it must be due to effectiveness. Most statisticians would look at each measurement separately, and say that each of them looked like it was due to luck, rather than effectiveness.

Since this was a phase-II trial, it was not large to begin with, and focusing on just the 12-18 year olds makes size even smaller, which is a handicap in a study like this.  Another way to view this conflict is as follows: was the clinical trial unsuccessful (poor p values) because the treatment was not effective, or was it unsuccessful (poor p values) because it was small?  Basically, if the trial were larger, would the p values have improved or would the effectiveness have diminished?

However, the path forward is the same in any case.  The researchers must do a follow on trial, which specifically recruits enough people between the ages of 12 and 18, to if the treatment is effective or not.  It is the success of that follow on study which will determine if the research continues or not.

Clinical Trial Record: https://www.clinicaltrials.gov/ct2/show/NCT02005848
Press Release: https://globenewswire.com/news-release/2017/11/01/1172203/0/en/Kamada-Announces-Top-line-Results-of-Phase-2-Trial-of-Alpha-1-Antitrypsin-in-Newly-Diagnosed-Type-1-Diabetes-Patients.html

The Scorecard

However, there is another issue with AAT.  This is not the first data we've seen on this treatment.  Part of the reason I'm nervous about the results from this study, is that I know the results from previous studies, and none of them are particularly good.

Study Number  Phase Size Sponsor   Duration  Completion Date Results
NCT01304537     I    24  Kamada    1 year    November 2012   No strong results
NCT01319331     I    15  Omni Bio  2 years   September 2013  No strong results
NCT01183468    II    16  NIAID     2 years   November 2014   Terminated
NCT01183455    II    66  NIAID     2 years   November 2014   Withdrawn
NCT01661192    II    12  Kamada    3 years   December 2016   Future publication
NCT02005848    II    71  Kamada    1 year    December 2017   This study
NCT02093221    II    76  Grifols   1 year    November 2017   Unsuccessful

Here is my previous blogging on the first two:
http://cureresearch4type1diabetes.blogspot.com/2015/09/aat-completes-phase-i-trial-no-strong.html
http://cureresearch4type1diabetes.blogspot.com/2012/06/possible-cures-for-type-1-in-news-june.html


Joshua Levy
http://cureresearch4type1diabetes.blogspot.com 
publicjoshualevy at gmail dot com 
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF or JDCA news, views, policies or opinions. My daughter has type-1 diabetes and participates in clinical trials, which might be discussed here. My blog contains a more complete non-conflict of interest statement. Thanks to everyone who helps with the blog.

Research In The News (March)

Here are a few updates related to possible cures for type-1 diabetes being tested in people:

Grifols Therapeutics Completes Recruiting on a Phase-II Trial of AAT

In February 2016, Grifols completed recruiting people for their phase-II trial of AAT (Alpha-1 Antitrypsin).  This is a 76 person study with two different dose treatment groups and a placebo group. Assuming the study progresses normally, they will finish collecting data in February of 2018 and publish the year after that.

AAT is an anti-inflammatory / immunomodulatory drug, which the body makes naturally, and which is already FDA approved for people who have a rare condition where they don't make enough of it on their own. Using AAT to treat type-1 diabetes is based on the idea that one of AAT's effects (lowering inflammation, immune modulation, or wound healing) can cure/prevent/treat the disease.  My previous blogging on AAT is here:
http://cureresearch4type1diabetes.blogspot.com/search/label/AAT

Discussion: My summary of AAT's status is this: after several phase-I studies which did not give a strong signal of success, we now have two phase-II studies (the other is Kamada's involving about 60 people) and these will finish collecting data in 2016 and 2018, respectively.   When those two trials are published, we should have a clear success/failure signal.

Previous blogging on AAT: http://cureresearch4type1diabetes.blogspot.com/search/label/AAT
Clinical Trial Record: https://clinicaltrials.gov/ct2/show/NCT02093221

Combo of Diamyd and Vitamin D Starts a Phase-II Prevention Trial

This is a classic prevention trial.  The researchers will enroll 80 children (between 4 and 18) who are positive for two autoantibodies (GAD and any one other), but not yet showing any symptoms of type-1 diabetes.  These people will be followed for 5 years to see how many are diagnosed in that time. This study started in March 2015 and is expected to finish in March 2022.  Half the children will be given Diamyd and Vitamin D, the other half, just Vitamin D.

Diamyd is similar to GAD, which is the target of the most common autoantibody seen in type-1 diabetes.  The hope is that Diamyd will train the immune system not to autoattack.

This study is enrolling "by invitation only", so if you are interested in enrolling, you can contact Dr. Helena Elding Larsson at Lund University, Clinical Research Center, Pediatric Endocrinology, Jan Waldenströms gata 35, 60:11 Malmö, Sweden, 20502

Discussion: Diamyd was unsuccessful at curing honeymoon type-1 diabetes in a large phase-III clinical trial and also unsuccessful in curing adult onset type-1 diabetes, but their earlier, smaller phase-II trial showed better results, so this study is testing it as a preventative. According to TrialNet research, essentially all of the people in this trial will eventually be diagnosed with type-1, but not within 5 years.  It will be interesting to try to match up the numbers from this study and TrialNet.

Clinical Trial Record: https://clinicaltrials.gov/ct2/show/NCT02387164

Combo of Diamyd, Vitamin D, and Etanercept Starts a Phase-II Trial

This trial will test a combination of Diamyd, Vitamin D, and Etanercept as a cure for type-1 diabetes.
The trial will enroll 20 honeymooning children (ages 8 to 18), all of whom will get the treatment. There will be no control group.  People will be followed for 2 1/2 years, checking for C-peptide (natural insulin generation), A1c, and insulin, plus a bunch of safety measures and immunological measures.  This trial is expected to finish in November-2018, but that will only happen if they are fully enrolled by May-2016, which is coming up quickly!

The hope for this trial is that Diamyd will stop or lower the autoimmune attack, Etanercept will lower inflammation and stop the immediate loss of beta cells, and Vitamin D will do some unspecified good (based on the fact that countries closer to the equator have more sunlight so more Vitamin D and less type-1 diabetes).

They are recruiting people all over Sweden:
Eskilstuna Hospital -- Eskilstuna, Sweden -- Contact: Ulf Söderström, MD      
Helsingborg Hospital -- Helsingborg, Sweden -- Contact: Anna-Karin Albin, MD      
Linköping University Hospital -- Linköping, Sweden -- Contact: Johnny Ludvigsson, MD      
Lund University Hospital -- Lund, Sweden -- Contact: Annelie Carlsson, MD      
Skåne University Hospital, UMAS -- Malmö, Sweden -- Contact: Tore Vigård, MD      
Sachsska, Södersjukhuset -- Stockholm, Sweden -- Contact: Björn Rathsman, MD      
Uddevalla Hospital -- Uddevalla, Sweden -- Contact: Ragnar Hanås, MD      
Västerås Hospital -- Västerås, Sweden -- Contact: Carl-Göran Arvidsson, MD      
Örebro University Hospital -- Örebro, Sweden -- Contact: Stefan Särblad, MD

Discussion: Diamyd has been tested in much larger trials, and has not been found effective.  Vitamin D has not yet been tested in an intervention trial (and the news is mixed from population studies), but Etanercept did have one successful phase-I trial, but it did not (by itself) rise to the level of a cure. I've blogged about all these separate treatments, but this is the first study I know of which combines them:
http://cureresearch4type1diabetes.blogspot.com/search/label/Diamyd
http://cureresearch4type1diabetes.blogspot.com/search/label/Vitamin%20D
http://cureresearch4type1diabetes.blogspot.com/search/label/Etanercept

Don't mix this research up with the DIABGAD trial (also done by Dr. Johnny Ludvigsson), which combined Diamyd, Vitamin D, and Ibuprofen.  Although the two projects are similar in that they are both Diamyd plus Vitamin D and an anti-inflammatory.  Ibuprofen and Etanercept are both anti-inflammatories, although they use different mechanisms: Ibuprofen is a COX inhibitor, while Etanercept is an TNF inhibitor.

Clinical Trial Record: https://clinicaltrials.gov/ct2/show/NCT02464033

Joshua Levy 
http://cureresearch4type1diabetes.blogspot.com 
publicjoshualevy at gmail dot com
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF or JDCA news, views, policies or opinions. My daughter has type-1 diabetes and participates in clinical trials, which might be discussed here. My blog contains a more complete non-conflict of interest statement. Thanks to everyone who helps with the blog.

Research In The News (January)

These are a couple of old news items that I'm catching up with.

Kamada Changes Phase-II Alpha-1 Antitrypsin (AAT) Study
Kamada has announced a major change to their Phase-II trial of AAT.  Although there are several AAT trials underway, this is the farthest along, and the largest.  You can read my previous blogging here:
http://cureresearch4type1diabetes.blogspot.com/search/label/AAT

AAT is an anti-inflammatory / immunomodulatory drug, which the body makes naturally, and which is already FDA approved for people who have a rare condition where they don't make enough of it on their own. Using AAT to treat type-1 diabetes is based on the idea that one of AAT's effects (lowering inflammation, immune modulation, or wound healing) can cure/prevent/treat the disease.

Prior to the change: The trial would collect data on 180+ people for two years.  The first half would be double blind, but at the half way point (90 people and 1 year) the data would be analysed unblinded, to check for safety and do futility analysis.  Results from the completed trial probably would not be published until 2019, maybe longer, depending on how long recruiting took.

After the change: The 60 patients enrolled by the end of 2015 will be followed for one year, and then results will be published, probably in 2017.

What does this mean?  It means we will see results from this trial quicker than originally planned, but it also means there will be less data.  Is this good or bad?  I thought about this question quite a bit, and there are two ways to answer that question.  From my point of view, this is good, because it will mean that we have results faster.  It is true they will not be as definitive, but my gut reaction is that if there is clear good news, then it will show up even in a 60 person study.  The only danger is that with 60 people, the results will not be clear.  But my belief is that if they are not clear with 60 people, then the answer is "no".  I think it's unlikely that a drug which is so-so with 60 people is going to show as a cure with 120 or 180 people.

Of course, another question is, do these changes mean that Kamada thinks the drug is working, or do they mean Kamada thinks the drug is failing?  My answer to that is "I don't know".  The trial is double blind, so officially Kamada should not know anything about the outcome.  Even if they did, good results could motivate them to speed things up, but so could bad results (to lower expenses). I don't see a good way to "read meaning" into a shorter trial.

In the non-scientific world, it could mean that the company is running low on money, or that it is harder than expected to recruit people for the study.  As originally designed, this study would require 180+ honeymooners to enroll in one country: Israel.  That's a lot of fish to pull out of a small fishing hole.  (My very "back of the envelope" calculations suggest that about 350 people are diagnosed with type-1 in Israel per year, so you'd need to get about half of them to enroll.  If you recruited for two years then "only" 1/4 of everyone diagnosed in the entire country would need to sign up. That is hard.)

Press release: http://www.businesswire.com/news/home/20151202005422/en/Kamada-Update-Alpha-1-Antitrypsin-Development-Newly-Diagnosed

About the inhaled version (being tested for a different disease):
AAT is already approved as an intravenous injection for treating AAT deficiency.  This is not the same type of injection as insulin; it generally requires a trip to a clinic for treatment.  However, Kamada is also testing an inhaled form to treat AAT deficiency.  If this is approved, and if AAT is found to work for type-1 diabetes, then having different forms will be convenient.  They have finished enrolling their inhaled AAT study, which is a good milestone:
http://www.businesswire.com/news/home/20151208005129/en/Kamada-Completes-Enrollment-U.S.-Phase-2-Study



Albiglutide Starts a Phase-II Trial

Albiglutide (tradenames Eperzan and Tanzeum) was approved in both the USA and the EU in 2014. It is a Byetta-like drug, designed to be used once per week, so the dosing is more like Victoza.  Like both of those drugs, Albiglutide is part of a large class of drugs called GLP-1 inhibitors.  All of these drugs are commonly used by people with type-2 diabetes.  It is not clear to me why it would cure type-1, but GlaxoSmithKline is testing it in type-1 diabetics, and it might improve A1c numbers.

This trial involves about 68 people, of whom 51 will get the drug and 17 will be in the placebo group.

The trial will take about 17 months per person.  Two months of pre-treatment screening, 12 months of treatment, and three months of post treatment monitoring.  They started in November 2014 and hope to finish by December 2016.

They will be recruiting people at about 29 different sites, in five different countries (France, UK, Germany, Italy, and Spain).  See the complete list in the clinical trial record below.

Clinical Trial Record: https://clinicaltrials.gov/ct2/show/NCT02284009
Wikipedia: http://en.wikipedia.org/wiki/Albiglutide

My plan is to follow this study, and see if this drug turns out to be a promising treatment, a promising cure, or neither.  If it doesn't show cure potential, I will stop covering it.

If this drug does prove useful in curing (or even treating) type-1 diabetes, there are several other widely available drugs in the same category which could be tested (some are available for off label use immediately). In addition to Victoza and Byetta there are: Bydureon, Dulaglutide, and Lixisenatide.

Joshua Levy
http://cureresearch4type1diabetes.blogspot.com
publicjoshualevy at gmail dot com
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF or JDCA news, views, policies or opinions. My daughter has type-1 diabetes and participates in clinical trials, which might be discussed here. My blog contains a more complete non-conflict of interest statement. Thanks to everyone who helps with the blog.

AAT Completes a Phase-I Trial (No Strong Results)

AAT is an anti-inflammatory / immunomodulatory drug, which the body makes naturally, and which is already FDA approved for people who have a rare condition where they don't make enough of it on their own. Using AAT to treat type-1 diabetes is based on the idea that one of AAT's effects (lowering inflammation, immune modulation, or wound healing) can cure/prevent/treat the disease.

Kamada (makers of one form of AAT) recently published the results of a Phase-I trial in honeymoon type-1 diabetics.  There are several AAT clinical trials going on, and I've reported on different results before:
http://cureresearch4type1diabetes.blogspot.com/search/label/AAT

AAT Completes a Phase-I Trial (But No Strong Results)

This study was open label, with no control group.  A total of 24 people were divided into three groups and each group got a different dose [d1].  Primary end points were safety related, but effectiveness was measured in secondary end points.  The study lasted 37 weeks.  The patients got a total of 18 doses of AAT, spread out over the first 28 weeks of the trial.

The results were:

• No serious adverse events occurred, and non-serious adverse events were not dose dependant.
• Average hemoglobin A1c decreased from 8.4% to 7.1% [my rounding]. 
• C-peptide levels dropped during the study, but the researchers felt that they dropped less than seen in untreated people from other studies.  At the end of the study, 18 subjects (75%) had a peak C-peptide ≥0.2 pmol/mL. 
• At the end of the study 1/3 of the subjects met the definition of "possible responder" meaning their C-peptide numbers had gone down 7.5% or less.

Opinions of Results

First, no serious adverse events is a good safety result, and having non-serious adverse events be non-dose dependent is also a good safety result.  If there were safety issues, they would likely get stronger as the dose gets higher, since that did not happen, it is likely that these adverse events were not related to the treatment.   So it looks like it passed the safety part of the trial.

Because this study was done on youth between 10 and 18 years old, showing a good safety profile is particularly important.  It is likely to open up future trials to youth.  Recruiting youth speeds the clinical trial process (especially in the honeymoon phase) because type-1 is so often first diagnosed in children.  The safety profile might also lower barriers to "off label" use of this drug [d2]. 

Now an optimist would say "phase-I tests safety and safety is OK, so trial is a success". However, they did measure effectiveness also, and so I do think it is important to look at the effectiveness numbers that we have.  I have noticed that if the phase-I is not effective, it makes it less likely that the phase-II will be.  So with that in mind:

The most important thing to remember is that this study did not have a control group, and that makes interpreting the results difficult.  The A1c group, the C-peptide group, and the "responder" group all have the same fundamental difficulty: we know what happened to the treated people, but there is no untreated group to directly compare them to.  Therefore the researchers compare these people with untreated people from other studies; and I'm doing the same.   

I think that the drop in A1c levels was meaningless.  This was a honeymoon trial; people were recruited within 6 months of diagnosis.  That first A1c number covers either the early months of type-1 diabetes self treatment or the weeks just before diagnosis (or some of each).  These are both times of high A1c numbers.  Conversely, the second A1c number covers a time when the patient has between 6 and 12 months of experience with type-1, and is therefore better at treating their type-1. So of course the A1c numbers are better.

The researchers compare these A1c numbers to average A1c numbers in adults, and note that the first is above average while the second is below.  However, for the reasons described above, I don't think this is a case where comparing to average is an appropriate thing to do.  

For the C-peptide data, I think the data is hard to interpret, but disappointing.  The researchers summarized their findings this way:

subjects treated with AAT showed less of a decline in C-peptide levels as compared with historical controls.  However, in the absence of a randomized control group, these findings should not be interpreted as showing a beneficial effect on beta cell preservation
and glycemic control.

For me "less of a decline" is the very smallest sign of success a researcher can talk about.  I'd put these results below results from TOL-3021 and Alefacept  (both which held C-peptides constant), and maybe even Teplizumab (which held C-peptides constant in some people).

Each person has to decide for themselves which results excite them, and which don't.  For my part, in honeymoon trials, results where the C-peptide numbers go up (after a year) excite me.  Results where they stay constant are unexciting.  And, results where they go down are disappointing.  Here the average went down.

People in this study will be offered a chance to participate in a long term (3 year) follow up study. Those who still generate C-peptides [d3] will be kept on their current dose of AAT.  Those who don't (or who don't want to continue, will not get AAT, but will be followed as a comparison group.

Overall Status of AAT As A Cure For Type-1

AAT is unusual, in that there are two different types of information on it.  There are results of previous clinical trials.  But there are also anecdotal reports from the popular press.  The anecdotal reports are far more positive.   Unfortunately, these phase-I reports are clearly in line with the previous clinical trial results.  They are lackluster and will not lead to a cure without a large improvement in effectiveness.

The good news is that there are two phase-II clinical trials of AAT already underway, so there is nothing to do but wait.  Especially since one of those phase-II trials is being done by the same company as did this trial: they have incorporated what was learned from the older trial into the design of the newer trial.  If there are good results from the phase-II trials, then AAT is in good shape.   Mediocre results in phase-I mean nothing if the phase-II results are good.  If those results are as good as the anecdotal results, then AAT is in great shape.  But if those phase-II results are similar to these phase-I results, then that would be bad news for AAT.

Opinionated Discussion of Footnote 30

Because this study did not have a control group of it's own, the researchers used control group data from other studies.  In particular, some control group data from the phase-II trial of DiaPep 277, and this reference was provided in footnote 30.   In my opinion, using this data raises a red flag.  One of DiaPep's phase-III trials was canceled because of serious scientific misconduct [d4].  The article reporting the results of the other phase-III trial was retracted because the same misconduct was found in that study as well. To my knowledge, no misconduct has been found in the phase-II trial, but none was particularly looked for, either.  And there are authors in common between the retracted phase-III paper, and the cited phase-II paper [d5]. Finally, the manipulation that was done in the phase-III paper changed both the treated group and the control group [d6].  So if that same manipulation was done to the phase-II trial, (that is a big "if" of course) then it would effect the exact data that these AAT researchers are using.

For all these reasons, I think using data from the DiaPep 277 phase-II study is a mistake.  The AAT researchers were using control group data.  Lots of studies have control groups.  Why use potentially tainted data, when untainted data is available?

Thanks

I want to specifically thank the author of this paper who sent me a copy of the full paper, so I could comment on all of the paper, and not just the abstract.

More Discussion

[d1] The researchers listed this trial as "Phase-I/II".  Generally I consider phase-I to be less than 20 people, and phase-II to be larger than that, but I also expect a Phase-II to have a control group, which this did not.  So based on the whole trial, I consider this a phase-I trial.

[d2] In the USA once a drug or device is approved, a doctor can prescribe it in situations different than it was originally approved for.  As an example, a doctor may prescribe it for a different disease, at a different dose, or for a different type of person than it has been approved for.  In the world of type-1 treatments, drugs or devices that have been approved for use on adults are often prescribed for children.  This is a classic "off label" use.  Off label use is based on the professional opinion of a doctor, and consent of the patient.  Therefore safety data (such as from this study) can make doctors more willing to prescribe "off label", and patients more interested in trying it.

[d3] Specifically, patients who have C-peptide levels of ≥ 0.2nmol/L will be able to continue their AAT regimen.  Note also that I refer to the other group as a "comparison" group and not a "control" group.  These two groups start off different, so I don't consider one to be a good control for the other.

[d4] Hyperion used the term "serious misconduct" in describing the situation, and Globe News used the term "fraud".

[d5] I want to stress that there were authors who only worked on the phase-II paper, and there were authors who only worked on the phase-III paper.  And, there were authors who worked on both papers.  To my knowledge, there has never been a public naming of who was involved in the misconduct, so there is no way to know if one of the authors was involved or if it was someone else in the organization, or even how many people were involved.

[d6] A more complete discussion of the misconduct alleged in this case is in my previous blog posting:
http://cureresearch4type1diabetes.blogspot.com/2014/09/diapep277-development-canceled-due-to.html

References

Abstract: http://onlinelibrary.wiley.com/doi/10.1111/pedi.12283/abstract
Press Release: http://www.businesswire.com/news/home/20150706005216/en/Kamada-Announces-Publication-Pediatric-Diabetes#.VcY2xPlVhBc
Clinical Trial Record: https://clinicaltrials.gov/ct2/show/NCT01304537
Poster: http://www.kamada.com/files/files/Prduct%20Development/Diabetes_print%20Jan13.pdf
Follow On Study Clinical Trial Record https://clinicaltrials.gov/ct2/show/NCT01661192

Joshua Levy 
http://cureresearch4type1diabetes.blogspot.com 
publicjoshualevy at gmail dot com 
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF or JDCA news, views, policies or opinions. My daughter has type-1 diabetes and participates in clinical trials, which might be discussed here. My blog contains a more complete non-conflict of interest statement. Thanks to everyone who helps with the blog.

Update On AAT

I'm about four months behind on reporting on AAT (Alpha 1-antitrypsin)
AAT is an anti-inflammatory drug, which the body makes naturally, and which is already FDA approved for people who have a rare condition where a person don't make enough of it on their own. Using AAT to treat type-1 diabetes is based on the idea that treating inflammation can cure/prevent/treat the disease.

Here is a link to my previous blogging:
http://cureresearch4type1diabetes.blogspot.com/search/label/AAT

Recent Clinical Trial Results

Results of a phase-I clinical trial of AAT were recently published.  This trial included 12 people and had no control group (so was not blinded nor was it randomised).  The 12 people were recently diagnosed, and when the study started, were generating some of their own insulin.  The abstract is included (in full) below.  My summary is that the study found several changes to immune cells, when comparing the situation before and after dosing with AAT.  However, no differences were reported in the abstract for A1c numbers or amount of injected insulin.   They did report that C-peptide generation went up or stayed the same for 4 patients; the implication is that it dropped for 8 patients.  To me, that seems pretty normal for honeymoon diabetics, so the effects for C-peptide seem to be very small (or nonexistent).  Because there was no comparison group, it's hard to tell if the treatment improved C-peptide generation or not.

My summary of these results are that they might be important to immunologists who are trying to learn more about curing type-1, but it's not the kind of result that's directly applicable to curing type-1 diabetes.  Particularly: there is no mention of anyone going insulin free for any length of time.  Remember that.  In terms of "clinical results" (ie. the kind of results that would matter to a person with type-1 diabetes: C-peptide, A1c, and insulin usage), the results are either tiny, tiny, or nonexistent.

This result is similar to previously released results from other studies, showing very modest results.  I've blogged about those before, at the link above.

Recent Publicity from Anecdotal Results

Additionally, there have been two "anecdotal reports" on AAT effectiveness, both sourced from Dr. Eli Lewis, who is one of the researchers involved.  One was several months ago, the other just a month or two ago.  I call these "anecdotal" because they are not reported in the scientific literature and have not been peer reviewed.  In general, the media reports far less data than a medical journal would report.  Obviously, none of them can be used to get FDA approval.

The Oct 2013 Report

The first anecdotal report was in the news in October 2013.  It reported on a family where the son was diagnosed with type-1 diabetes.   Six month later, the daughter was diagnosed with type-1 diabetes, but the family contacted Dr. Lewis and was able (with some difficulty) to get an off-label prescription for AAT.  The daughter was given AAT, and was cured of type-1 diabetes.   The daughter did not use insulin for years afterward.  Just recently, after about 3 years without using insulin, the daughter has started to use some, but at an extremely low level.

Obviously, that sounds wonderful; what every newly diagnosed type-1 diabetes patient wants to hear.  The father believes that the AAT helped delay the time when insulin had to be used.

The Feb 2014 Report

Later, in February 2014, Dr. Lewis was quoted in news articles as follows:

Following treatment of eight to 12 weeks with AAT, in several patients, it allowed proper glucose levels to be controlled without the need for any insulin injections for more than two years

We believe we will see similar results in a number of U.S.patients who recently received this treatment outside the trials within several months of diagnosis and are still completely insulin free.

Again: sounds like exactly what a honeymoon cure would be.

You may ask, if this drug is in phase-I trials, how can people in the US get it, outside of the clinical trial?  The answer is that those people are being treated "off label".  Because AAT is approved for one illness (alpha 1-antitrypsin deficiency) a doctor can prescribe it for any illness, even if it is not specifically approved for those other illnesses.  This is a quirk of the USA's drug regulations, but it is an important one.

Discussion

I suspect that we might be seeing a conflict between two different ways of diagnosing type-1 diabetes.  The historical method, which I'll call "method A" is that a child starts peeing a lot, and/or drinking a lot, and/or losing weight (often while being hungry all the time), and generally feeling awful.  The doctor checks BG, which is very high, and the person starts using insulin.  Things get much better relatively quickly.  However, there is another way of being diagnosed, which I'll call "method B".  In method B, the child is showing relatively minor symptoms, or maybe none at all.  But they are given a blood sugar test after a meal, and their BG numbers are over 200, which means they have diabetes.  It used to be that type-1 was diagnosed using method A only.  But now, thanks to TrialNet, and heightened awareness, a few people are diagnosed with method B.    But people diagnosed with method B may not need to start using insulin right then.  We don't know a lot about the natural disease progression in people who are diagnosed via method B.  It may be normal (or at least common) for them to go months or years without insulin even without AAT treatment.

Because I've spoken with the father of the child in the first anecdotal report, I know that child was diagnosed using method B.  She did not use insulin before AAT treatment nor did she need it for years afterwards.  But the key question is: was that because she got the AAT, or was that the normal progression of someone diagnosed with method B?

I don't know if that also happened with the second anecdotal report.  One of the problems with scientific results reported via researcher's quotes in the popular media, is that we don't know the most basic information about what was going on.  In this  case: how were the people diagnosed with type-1 diabetes, and were any of them using insulin before AAT treatment?

The difference between these results (the clinical trials vs. the anecdotal results) is very troubling to me.  Going insulin free for years is huge news.  But it's not mentioned in the journal article.  Why not?  If those results were seen in the people in the clinical trials, they would certainly be in the paper.  But if they were not seen in the clinical trial patients, then why did the non-trial patients do so much better than the clinical trial patients?

For me, there's no question which source of information to weigh more heavily, right now.  It's got to be the clinical trial results.  Those are the results where we know more details.  Those are the results that were peer reviewed.  Those are the results that the research community will examine.  And, those are the results that the FDA will eventually use to approve new drugs, or (in the case of AAT) new uses for existing drugs.  Unfortunately, for AAT, the clinical trial results are much smaller than the anecdotal results.

I was able to talk with Dr. Lewis about this research, and heard him speak about it to a lay audience.  He believes that the "off label" patients had better results because their doctors could be much more flexible with the dosing.  When you're in a clinical trial, you get the dose that the trial says you get.  That's it.  However, in "off label" use, the doctor can tailor the dosing to each individual person, and how they react to the treatment.  Dr. Lewis believes that this customization of dosing resulted in the much better results he talked about.

Dr. Lewis also made two other points which bear repeating:  First is AAT's great safety profile.  It has been used on a wide variety of people, over a long time, and has a record of safety.  Second, although AAT is an anti-inflammatory, it may work differently than "classic" anti-inflammatories.  Classic inflammation works like this: some cells are damaged, and those cells and nearby cells chemically signal the immune system for help.  The immune system responds with inflammation.  This information attacks foreign and dead cells, but it also damages nearby cells (a sort of "collateral damage").    Dr. Lewis believes that AAT works by helping to save these "bystander" cells from this inflammatory damage, without lowering the entire response.  Classic anti-inflammatories lower the whole inflammation reaction.

What Next?

Kamada, the company that produces AAT is starting a phase-II/III clinical trial in Israel, which I will discuss in a future posting.  This is very good news, of course, because if those anecdotal reports mean what we hope they mean, then the data from the phase-II trial will show it.  The phase-II trial will have a placebo group, and will be much larger than the phase-I trial, so any effect as large as a cure (even a temporary one) will be obvious.

Also, there are several other AAT clinical trials already underway.  The recent publication was one of three similar studies.  So the publication of the other studies, which should happen shortly, will also be informative.

Sources

Below are links to abstracts and press releases on the clinical findings, and news articles on the anecdotal reports.  I did speak with the father of the first anecdotal report, and included some information from him.  He did review this posting to ensure that the information from him was accurate, and that he was comfortable with the amount of information I was making public.  I also emailed with Dr. Lewis, and heard him speak.   As always, all mistakes are my own.

Clinical Trial Results:
http://www.ncbi.nlm.nih.gov/pubmed/24527714
http://press.endocrine.org/doi/pdf/10.1210/jc.2013-3864

Below is the complete "Results" section of the abstract:

Results: No adverse effects were detected. AAT led to increased or unchanged levels of C-peptide responses compared to baseline in four patients. The total content of TLR4-induced cellular IL-1β in monocytes at 12 months following AAT therapy was 3-fold reduced compared to baseline (p < 0.05). Furthermore, at baseline, 82% of monocytes produced IL-1β, but at 12 months post-therapy the level decreased to 42%. Similar reductions were observed using TLR7/8 and TLR3 agonists in monocytes and mDCs. Unexpectedly, the reduction in cellular IL-1β was observed only 9 and 12 months post-treatment but not in untreated diabetics. Improved beta cell function in the four AAT-treated individuals correlated with lower frequencies of monocytes and myeloid DCs producing IL-1β compared to subjects without improvement of islet function (p < 0.04 and p < 0.02, respectively). Conclusions: We hypothesize that AAT may have a beneficial effect on T1D in recently diagnosed patients that is associated with downmodulation of IL-1β.

Researcher's Web Page:
http://www.lewislab.net/Teaching/Lewis_Lab_Friendly_Update_page.html

Oct 2013 Reports:
http://www.jweekly.com/article/full/69881/israeli-doctors-diabetes-treatment-draws-hearty-todah-rabah-from-s.f.-diplo/?fb_action_ids=10151792538577374&fb_action_types=og.recommends&fb_source=other_multiline&action_object_map=%7b%2210151792538577374%22:482058221892936%7d&action_type_map=%7b%2210151792538577374%22:%22og.recommends%22%7d&action_ref_map=%5b%5d
http://www.aabgu.org/media-center/bgu-making-a-difference/targeting-diabetes-from-the-negev.html

Feb 2014 Reports:
http://jewishbusinessnews.com/2014/02/24/first-clinical-trial-of-type-1-diabetes-treatment-has-extremely-positive-results/
http://news.xinhuanet.com/english/health/2014-02/25/c_133140280.htm

Phase-II/III Trial:
http://www.businesswire.com/news/home/20140305005510/en/Kamada-Initiates-Phase-23-Clinical-Trial-Glassia#.UzEZBfldXgc
http://clinicaltrials.gov/ct2/show/NCT02005848


Joshua Levy
http://cureresearch4type1diabetes.blogspot.com 
publicjoshualevy at gmail dot com 
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF, JDCA, or Tidepool news, views, policies or opinions. My daughter has type-1 diabetes and participates in clinical trials, which might be discussed here. My blog contains a more complete non-conflict of interest statement. Thanks to everyone who helps with the blog.

Possible Cures for Type-1 in the News (early January)

This posting covers two news items and discussion to go with each.  I'm about 4 months behind on blogging about current events that might lead to a cure or prevention of type-1 diabetes.  Even after this posting, I'll still be several months behind.  I hope to catch up by end of January.

As you read these summaries, remember that C-peptide is generated when your body makes it's own insulin, so more C-peptide means your body is generating more of it's own insulin.

Results from Alefacept in a Phase-II Trial ("T1DAL")

Alefacept is a drug that has been used to treat the skin condition, psoriasis.  Psoriasis is generally considered to be an autoimmune disease, similar to type-1 diabetes, but with the body attacking it's own skin cells, rather than it's own beta cells.  So trying a drug already approved for Psoriasis on type-1 diabetes seemed like a reasonable thing to do, and these researchers did it.  You can read my previous blogging here:
http://cureresearch4type1diabetes.blogspot.com/search/label/Alefacept

This was a honeymoon trial.  33 people got the drug and were compared to 16 who did not.  The treated group got a dose a week for 12 weeks, then a 12 week break, and then weekly doses for 12 more weeks.  They will be followed for 2 years, but these results only cover the first year.

Results

There were six results:
1. A two hour after eating C-peptide test: Treated generated about 0.130 nmol/L more than untreated, but this was not statistically significant.  However, all the rest of the results were statistically significant:
2. A four hour after eating C-peptide test: Treated generated about 0.171 nmol/L more than untreated.
3. Daily amount of insulin used: Treated people used about 25% less insulin.
4. Number of low BG events: Treated people had 10 such events vs. 17 in untreated.
5. No difference in A1c numbers between treated and untreated groups.
6. No serious adverse effects occurred.

Discussion

This is a good news / bad news kind of study.  I'll give you the bad news first:
* Because the first measure was the primary end point, this trial failed it's primary end point.  The others were secondary end points, some of which were successful.

Good news second:
* In for both of the C-peptide numbers, the treated group actually went up (a tiny amount) in the year after diagnosis, while the untreated group went down. So it is possible, that using this drug earlier in the process will preserve more beta cell function.
* Using 25% less insulin (with no difference in A1c numbers), and having half the low BG events both seem promising to me as well.

But the important thing to remember about this study, is that Alefacept is no longer on the market.  When this study started, it was being sold as an anti-Psoriasis drug.  However, the manufacturer withdrew it from the market while this study was running.  (The study was a little smaller than planned, because of that.)  The drug was not subject to any kind of recall prior to the withdrawal.

Because the drug is no longer on the market, I'm not sure if this research will move forward or not.

News: http://medicalxpress.com/news/2013-09-psoriasis-drug-results-diabetes.html
Abstract: http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70111-6/abstract
Web page: http://www.immunetolerance.org/news/2011/04/itn-announces-enrollment-first-participant-t1dal-trial-people-recently-diagnosed-type-1
Recruiting web site: http://www.t1dal.org/
Clinical Trial: http://www.clinicaltrials.gov/ct2/show/study/NCT00965458

Official Notice of Withdrawal: http://www.amevive.com/Patient%20letter.pdf


Results from Extended AAT (Glassia) Phase-I/II Trial

There are two pieces of news on AAT.  One is the results of an extension to their phase-I clinical trial, the other is informal news of a specific case study.  In this blog posting, I'm only covering the phase-I trial.  I'm gathering more information on the case study, and will present that in a future blog posting (probably at the end of January).

AAT is an anti-inflammatory chemical which the body makes naturally, and which is already FDA approved for people who have a rare condition where they don't make enough of it on their own.  There are several clinical studies going on, which use AAT.  In October, one of those studies released data on 20 people who were followed for 20 months after diagnosis.  There was no control group for this phase-I study. You can read more about AAT here:
http://cureresearch4type1diabetes.blogspot.com/p/drugs-and-treatments-in-clinical-trials.html

and my previous blogging here:
http://cureresearch4type1diabetes.blogspot.com/search/label/AAT

Results

Three results were reported:
* 60% of the patients where generating more than 0.2 nmol/L of C-peptide.
* 75% of the patients had an A1c of 7.5 or lower.
* No safety issues were found.

Because there was no control group, I can not directly compare these results to an untreated group of people.  However, my understanding is that both of these numbers are better than expected without treatment.  So this looks like good news, although not cure-type news, and without a comparison group, it's hard to tell.

Next Steps

Kamada is planning a phase-II/III study with 190 people.  The plan is for a double-blind, placebo-controlled, multicenter study on honeymoon type-1 diabetics.   The study will follow people for two-years measuring C-peptide parameters, HbA1C levels, hypoglycemic events, insulin daily dose, safety/tolerability, etc.  They will start in Israel, and expand elsewhere later.

Press Release: http://www.kamada.com/press_item.php?ID=73
The new study: http://clinicaltrials.gov/ct2/show/NCT02005848

Factoid: Type-1 Prevalence in USA Might be 1 in 500

Ten years ago, when my daughter was diagnosed, we were told that about 1 in 250 or 300 people had type-1 diabetes.  Over the years I've seen those numbers repeated many times for the US population, and they seem to fit in with what we see in schools.  Many with a few hundred students have zero or one type-1 diabetics, and those with several hundred often have one or two.   So it all makes sense.

However, a study recently published suggests that the actual number might be just under 1 in 500.  You can read the details at the link below, but they found a prevalence of 1.93 per 1000 in kids 20 and under:

Abstract: http://care.diabetesjournals.org/content/early/2013/09/11/dc13-1838.abstract.html?papetoc


Joshua Levy
http://cureresearch4type1diabetes.blogspot.com
publicjoshualevy at gmail dot com 
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF, JDCA, or Tidepool news, views, policies or opinions. My daughter has type-1 diabetes and participates in clinical trials, which might be discussed here. My blog contains a more complete non-conflict of interest statement. Thanks to everyone who helps with the blog.

Possible Cures for Type-1 in the News (January)

I feel like I'm about two month behind, but this will get me closer to current news.

Kamada Reports Early Results from A Phase-I Trial

News: http://www.globes.co.il/serveen/globes/docview.asp?did=1000799026&fid=1725
Press Release: http://www.kamada.com/press_item.php?ID=29
Clinical trial record: http://www.clinicaltrials.gov/ct2/show/NCT01304537

I struggled quite a while with their press release, but in the end, this is my summary:

Kamada releases results from their phase-I trial, which they describe as "positive". However the data in the press release is too vague for me to come to any conclusion about weather their drug worked. I'm looking forward to a complete, peer reviewed paper.

Kamada manufactures Alpha-1 Antitrypsin (AAT).   You can read more about it here:

http://cureresearch4type1diabetes.blogspot.com/p/drugs-and-treatments-in-clinical-trials.html

and my previous blogging here:

http://cureresearch4type1diabetes.blogspot.com/search/label/AAT

AAT is an anti-inflammatory chemical which the body makes naturally, and which is already FDA approved for people who have a rare condition where a person doesn't make enough of it on their own.

These are the first results from the first phase-I clinical trial completed.  Unfortunately, there was no control group for this trial, so there is no way to compare people who got AAT with people who did not. The company's press release said that "almost all patients reached glycemic control below 7.5%" and that "the majority of the patients maintained levels of C peptide higher than ... 0.2 pmol/mL".

None of that is bad news, but this trial was for honeymooners (within 6 months of diagnosis).  So none of those results sound particularly stellar to me.  This is where a control group would be particularly helpful, because we could have seen a difference between the two groups, if there was one.  Because people with type-1 diabetes naturally vary a lot during their honeymoon, it is at this time that control groups are most important.  

I've asked the company when the full results will be published, and those might be much more interesting.  At the very least we should be able to see how the C-peptide numbers change over the  study.  That can be compared to the "normal" drop during the honeymoon phase.  My general feeling is that if this data is all the data they publish, then the trial was a failure.  They need to publish more data, especially C-peptide changes to show success.

Discussion

This study is important for a couple of reasons.  First, because of the number of AAT clinical trials. I know of a five AAT clinical trials aimed at type-1 diabetes going on now.  That's a lot; more than any other single drug.  So having mediocre results from the first study completed is not welcome news for any of the others.  Second, because of it's impact on the inflammation theory of type-1 diabetes.  This theory holds that inflammation destroys the beta cells in the pancreas.  The autoimmune reaction triggers inflammation, but does not directly destroy the beta cells.  This theory has never been the majority viewpoint (most researchers think that inflammation is a side effect of the destruction of beta cells, rather than a cause) but it is an active minority opinion.  Since AAT is an anti-inflammation drug, it is one of the first drugs to test this theory.  Since AAT does not appear to have a strong effect, that suggests that the whole inflammation theory might be wrong as well.  That would be unfortunate, since stopping inflammation is a lot easier than stopping the auto-immune attack!  Because there are lots of anti-inflammatories out there, there would have been lots of potential drugs to prevent type-1, if this theory panned out.

It is interesting to me, that even though this study did not have a placebo group (an untreated group), they did have three different levels of treatment.  Some people got 40mg of AAT, some people 60mg, and some people 80mg.  The press release did not include any difference in results between these groups.  That's a little ominous for me.  For a drug that is effective, I would expect one dose to be the most effective; others less so.  On the other hand, if the drug has no effect, then all the groups would be the same, and in this case, no differences were reported.

LCT Updates

Background: LCT is developing an encapsulated pig beta cell cure for type-1 diabetes.
The coating allows blood sugar in, and insulin out, but does not allow the body's immune system to attack the beta cells. It also allows nutrients in and waste products out. This allows the beta cells to naturally grow and to react to the body's sugar by generating insulin which goes into the body's blood system. Meanwhile, the body's autoimmune attack can not target these beta cells, and you don't need to take any immunsuppression drugs (as you would for a normal beta cell transplantation).

When last we left LCT, they were finishing a small phase-II trial in New Zealand, and starting a small phase-II trial in Argentina.  Links to press releases for the results and the follow on trial are below:
http://www.lctglobal.com/html/blob.php/121122%20LCT%20-%20Strong%20interim%20results%20in%20Argentinian%20%20DIABECELL%20trial.pdf?attach=0&documentCode=4774&elementId=20084
http://www.lctglobal.com/html/blob.php/121122%20LCT%20starts%20DIABECELL%20Phase%20IIb%20trial%20in%20Argentina.pdf?attach=0&documentCode=4775&elementId=20084

The Argentinian Trial

All the patients got two rounds of implanted islet cells, 12 weeks apart.  Half the patients got a base level, and the other half got twice this level.  The patients who got more islets had better results, which were:

• average insulin dose reduced by 20%
• a reduction of HbA1c from a pre-transplant average of 8.6% to an average of 6.7% at 12 weeks following the second implant
• up to 70% reduction in unaware hypoglycaemic events.

Obviously, this isn't a cure in it's current form (but see below for follow on products).  This study involved a total of 8 people, and so an obvious thing to do is to expand it, and the expansion was also announced.  LCT will implant an additional 20 people, all at the higher dose level.  For me the most interesting information in their press release is this:

“We are using an ‘adaptive trial design’ for our pivotal studies and so the data generated in this 20 patient trial will likely form the foundation data for our registration package,” said Dr Andrea Grant, Chief Executive, LCT. “We remain on track to meet our goal of completing clinical trials of DIABECELL by 2015 and having a product commercially available by 2016.”

I'm not an expert in this area, but I would be surprised if they could register a new medical implant for use in the US based on data from one study of 20 people (and their previous studies which contain about 24 people all together).  Especially with no clinical trials actually done in the US.  I assume that commercial availability will be in one or more of the countries where they have done research: New Zealand, Argentina, etc.

If you want even more information, you can read their CEO presentation, also done in November 2012, here:
http://www.lctglobal.com/html/blob.php/LCT%20AGM%20CEO%20Presentation%20Nov%202012.pdf?attach=0&documentCode=4762&elementId=20084

Which includes a slide "DIABECELL -- The path to patients" which lists four studies:
      A New Zealand phase II study [8 people]
      An Argentinian phase-II study [8 people]
      An Argentinian phase-II/III study [20 people, discussed above]
      A New Zealand and/or German Phase-III study [unknown size, not discussed above]
That forth study would make more sense to me, although I'm still not sure that this would get them approved in the US.  For comparison, the recent anti-CD3 drug approval attempts used two 300 person studies, one of which was done in the US.  And the pivotal DiaPep277 studies on-going right now are the same: two studies of 300 people each.  Maybe implants require less, but that much less?

No News from Russia

I'm also a little mystified because LCT had previously announced that their product had already been approved for sale in Russia:
http://cureresearch4type1diabetes.blogspot.com/2010/12/lct-gets-commercial-approval-in-russia.html
However, since then I can not find any reference to anyone selling it in Russia, or LCT getting any revenues from such sales. (But I don't speak Russian so can't search effectively in that language. If there are any Russian speakers out there, who would like to do some searches, please look for "LCT Biomedical Limited" (the company name) and/or "Natalia Dolgova" (the first company director) and tell me if they are selling anything in Russia.  If you find the web pages, I can Google Translate them.  But so far, I haven't even found them.)

LCT General Update

It is very rare for any executive at a medical company to make predictions about the future.  There are all kinds of rules about what they can and can not say.  So I was quite surprised (and happy!) to see these public posts from "elliott" in a posting on www.islet.org.  Dr. Bob Elliott is a founder of LCT.

Multi-centre Phase 3 studies will comemnce Q1 2013 and be completes by Q1 2015.
Registration based on a successful outcome will take anything up to a year, so we anticipate the LCT product will be marketed by Q1 2016 ie three years from now.
It will not cure diabetes, but is likely to be a valuable way of treating unstable diabetes.
'Fast follower' products will start to be tested clinically in 2014.

'Fast Follower' refers to the next generation of products. We are always seeking ways to improve the product but each improvement as seen in preclinicla studies in animals has to be tested in humans.   I have not give up on the idea of complete insulin independence, and we are making steady progress.

'Unstable' diabetes is the indication we are working on in the trials. But of course all Type 1 diabetics have unstable blood glucose control to a greater or lesser degree, so it really becomes a matter of how bad things are. 

He also said that they have improved the product since the peer-reviewed results were published in 2007, with the implication that they expect better results in the future then they reported in 2007.

Note that his statement that "Registration ... will take anything up to a year" might be true in some countries, but my belief is that in the US, marketing approval (our version of commercial registration) takes 1 to 2 years, especially if measured from the end of a phase-III trial.  I would not be surprised if other countries where LCT operates have faster registration processes.

Finally, I want to say that although LCT describes this 20 person Argentinian trial as "Pivotal" and "Phase-III", I will continue to refer to it as phase-II because of it's size. To be honest, I've seen phase-I trials with more than 20 people enrolled, so I think calling it a phase-II is proper.  Now if LCT gets approval in the US based on a 20 person trial, then I might change my standards. :-)

LCT's web page is http://www.lctglobal.com

Rituxan Safety in Rheumatoid Arthritis

Rituxan (also known as Rituximab or MabThera) is a monoclonal antibody which is being tested as a possible cure, or part of a cure, for type-1 diabetes.  My previous blogging is here:
http://cureresearch4type1diabetes.blogspot.com/search/label/Rituximab
Monoclonal antibodies are a relatively new technology for developing drugs (only about 20 years old), but already about half of new drug approvals are monoclonal antibodies.  However, some people have expressed worries that, as a class, monoclonal antibodies are unsafe, or their safety profile is unknown or suspect.

This study is a big step towards putting those fears to rest. Since Rituximab is already approved for rheumatoid arthritis, these researchers followed people who used it for that purpose for many years.  The basic result was that people on the drug had a lower disease rate than similar people not on the drug:

The rate of serious infectious events for the 1,145 patients on Rituximab for more than 5 years was 2.76 per 100-person-years, and the rate for the 818 placebo patients in the studies was 3.6 per 100-patient years, they said.

"No new safety signals were observed with increasing duration of exposure including in patients with more than 5 years of follow-up."

"the rates of myocardial infarction [type of heart attack] (0.40 per 100 patient-years) and malignancies were consistent with those observed in epidemiological data from other RA cohorts (0.48 to 0.59 per 100-patient years for MI)."

News: http://www.medpagetoday.com/MeetingCoverage/ACR/35895

Note that many monoclonal antibodies have names that end in mab.  So if you see a drug named Joshuamab or Curecommoncoldmab or anything ending with mab, it is likely to be a monoclonal antibody.

Rituxan as an Injectable Drug

Currently, Rituxan must be given intravenously, rather than being injected under the skin, like insulin.  The difference is important, because intravenous administration usually requires a "medical setting" (like a hospital or clinic, or at least trained medical staff).  While we all know that under skin injections are commonly done everywhere and by anyone, with a little training.

Recently Roche announced publication of two studies showing that they had a formulation of Rituxan which could be injected and was "not inferior" to the intravenous formulation already approved.  Since "not inferior" is the FDA's requirement for approval in situations like this, that's good news.  Even better news is that the basic technology that they used to convert a previously intravenous formulation into an injectable formulation can be applied to other drugs as well.  So with luck, they will be able to make lots of drugs easier to administer.

Press release: http://www.roche.com/med-cor-2012-12-08b.htm

Update from Scott King on Islet Sheet Project

An Islet Sheet is a specific beta cell encapsulation technique, similar to what LCT is trying to do.  Because Islet Sheets have not yet started human trials, I don't follow this research very closely.  However, I know others are very interested in it, and Scott King posted an update on his blog, which you can read here:
http://www.hanumanmedicalfoundation.org/blog/2012/11/26/signal-breakthrough-islet-sheets-thrive-in-pig/

They are hoping for more animal trials in 2013.  King is a very insightful guy and previous blog postings are interesting as well.

Joshua Levy
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF or JDCA news, views, policies or opinions. My blog contains a more complete non-conflict of interest statement. 
Clinical Trials Blog: http://cureresearch4type1diabetes.blogspot.com
Cured in Mice Blog: http://t1dcuredinmice.blogspot.com/

Possible Cures for Type-1 in the News (Nov-2012)

Summary of Three Months of New Trials

This is a quick summary of all of the new clinical trials into type-1 that started between July 1st and October 1st, 2012.  These are trials which were entered for the first time during these three months.  I got this list from the FDA's clinical trial database, which is on line here:
www.clinicaltrials.com

37 New clinical trials in total
-- ----------------------------
14 Delivery / New Insulins / New Test Kits
06 Long Term Side Effects
03 Artificial Pancreas
03 CGM
01 AAT
01 Psychological
08 Other (1 of these was a Vitamin-D trial)

My only comment is that only one of these (the AAT one) might lead to a cure.  That's not a lot.

What's Up with AAT (alpha-1 antitrypsin)?

The new AAT study reminded me that there are now a total of five AAT studies ongoing, and that's enough to have a summary of AAT research, so here it is.

I've blogged on AAT before, here:
http://cureresearch4type1diabetes.blogspot.com/search/label/AAT
and some background on AAT is here:
http://cureresearch4type1diabetes.blogspot.com/p/drugs-and-treatments-in-clinical-trials.html


Study Number  Phase Size Sponsor   Duration  Completion Date
NCT01304537     I    24  Kamada    1 year    November 2012
NCT01319331     I    15  Omni Bio  2 years   September 2013
NCT01183468    II    16  NIAID     2 years   November 2014
NCT01183455    II    66  NIAID     2 years   November 2014
NCT01661192    II    24  Kamada    3 years   December 2016

Initially, that looks pretty good.  Unfortunately, one of these trials (the second one, by Omni Bio) released some early data, and this data was only slightly positive.  The treatment showed no benefit to people with established type-1, and relatively small improvements to people who took it soon after diagnosis.  No specific numbers were published, which I consider to be a bad sign.  The first complete study (Kamada's) should be done very soon, and that should give us a much better "feel" for the level of success.  By 2015 we should have results on four studies, which should be definitive.
Another Trial for Zhao's Cell Educator (if they raise money)

I've previously blogged on Zhao's work here:
http://cureresearch4type1diabetes.blogspot.com/search/label/Zhao

It looks like researchers in New Zealand are raising money specifically to replicate Dr. Zhao's work.

Here is their description of what they want to do:

In the first trial we would infuse activated stem cells back into the patient and measure their ability to switch the behaviour of aggressive T lymphocytes to ‘peaceful’ T regulator cells. Trials like this are occurring internationally but without the activation step, and results are not yet clear. The second trial will be similar to the Chicago study [Zhao's trial, which was actually done in China]. The stem cells from each person will be used in the laboratory to ‘condition’ their white blood cells in the laboratory, before re-infusing the white blood cells.

I don't usually put information about donating money in my blog posts, but I've gotten several requests for information on how to help fund Zhao.  I don't know how an individual can do that effectively, but the researchers in New Zealand have these instructions:

If you would like to make a donation towards this cause, then the Spinal Cord Society NZ website www.scsnz.org.nz provides a means for you to do that. An email plus a donation will ensure that your contribution goes only towards the joint SCSNZ-Diabetes research work.

Please remember: I know nothing about these guys or this organization.  I am not endorsing them!

News: http://www.scsnz.org.nz/assets/Uploads/diabetes-winter-2012-focus-2.pdf
News: http://www.stuff.co.nz/national/health/7914909/Stem-cell-study-holds-diabetes-cure-promise

I want to especially thank Brian Braxton for the information and sources he provided, and everyone else (there were several) who pointed this news out to me.

Joshua Levy
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF or JDCA news, views, policies or opinions. My blog contains a more complete non-conflict of interest statement.
Clinical Trials Blog: http://cureresearch4type1diabetes.blogspot.com
Cured in Mice Blog: http://t1dcuredinmice.blogspot.com/

Possible Cures for Type-1 in the News (June-2012)

News About Diabetes News

The biggest diabetes research meeting in the world is the American Diabetes Assoication (ADA) Science Sessions, which are in June (this year: June 8-12).  It is followed by the big European Association for the Study of Diabetes (EASD) Annual Meeting (this year: Oct 1-5).  So expect a lot of news over the next few months.  We are already seeing press releases from companies publicizing what they will report at these large meetings.

Phase-II Results from Autologous Hematopoietic Stem Cell Transplants by Li at Nanjing University

This is the third group to do a Burt-like cure for type-1 diabetes, and get similar results.
You can read my previous blogging here:
http://cureresearch4type1diabetes.blogspot.com/search/label/Burt

But the basic summary is this: for recently diagnosed type-1 diabetics, this is the closest to a cure there is.  People have gone years after this treatment without needing to inject insulin.  This result has been reproduced in both Poland and China, after originally being done in Brazil.  The down side?  Safety.  This treatment requires a full immune reboot.  Very approximately: They kill off your old immune system, and you regrow a new one, so for a few days (or a few weeks) you are very susceptible to infections and you stay in a special isolation ward in a hospital.  As far as I know, no one has died, but the risk is there.  Plus, there are long term risks.

From the abstract:

After [treatment], 11 of 13 patients required significantly reduced doses of insulin for adequate glycemic control, accompanied by reduced levels of glycosylated hemoglobin but increased C-peptide concentrations. Three patients achieved exogenous insulin independence for 7-54 months. [Meaning one person was functionally cured for 4 1/2 years.]

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22419704
Clinical Trial Record: http://www.clinicaltrials.gov/ct2/show/NCT01341899

Alefacept Finishes Enrolling a phase-II Clinical Trial

This study is also called "T1DAL", which I'm sure is pronounced "tidal".  This trial is being run by the Immune Tolerance Network, and they finished enrolling people in the trial on 30-April-2012.


This drug targets the immune system's T cells, and is already approved for treating "plaque psoriasis" which is an autoimmune disease similar to type-1 diabetes.  It has a good safety profile there. The hope is that by giving it to honeymoon type-1 diabetics, beta cells will be preserved.


Why is finishing enrollment important? For two reasons.  First, because it is now possible to predict when they will finish collecting data.  (This study collects data for 2 years, so they should have it done by May-2014.)  Second, because much of the uncertainty that surrounds clinical trials, is involved with recruiting participants.  It is often unclear how hard it will be to recruite people, and how long it will take.   But at this point, all that uncertainty is behind the researchers.  From now on, it is just gather data, then analize data, and then publish data.  Researchers have a lot more control over those later stages, then over recruiting people in the first place.


Trial Record: http://www.clinicaltrials.gov/ct2/show/NCT00965458


Company X Gets Orphan Drug Status for Drug Y

I often see headlines like the one above.  The most recent was "Andromeda Announces FDA Orphan Drug Designation for DiaPep277". I don't report that as news in this blog, because I don't consider it scientific progress.  Orphan Drug is a designation used by the USA and the EU.  Companies with such drugs have the legal right to sell them for a longer period of time without competition.  The idea is that the drugs target rare conditions, and companies could not profitably develop them, if they only got the benefit of "normal" legal protection, because the market would be too small.  So, if the condition is rare enough, then the government says it is an orphan drug, and then the company gets a longer period of time before others can manufacture the drug.  Now, type-1 diabetes is a very common disease (over 1 million people in the US alone, by most estimates).  So a type-1 diabetes drug would not qualify as orphan.  But drugs that only work in the honeymoon phase can get orphan drug status, because only a couple of tens of thousands people are in the honeymoon phase in the US at any time.  I'm not sure that was a result the people who originally wrote the law would have approved, but that is how the law has been implemented.

But in any case: this is good news for the company, because it mean bigger revenues (or longer revenues) if the drug is successful.  But it does not say anything about the chances of success for the drug.  It says more about the disease being treated, than the drug with the status.

Wikipedia: http://en.wikipedia.org/wiki/Orphan_drug

Omni Announces Some Phase-I Results for AAT

AAT is an anti-inflammatory drug, which the body makes naturally, and which is already FDA approved for people who have a rare condition where a person don't make enough of it on their own. This treatment is based on the idea that treating inflammation can cure/prevent/treat type-1 diabetes.

There are several trials currently underway with AAT.    Omni recently announced some information about the first 12 people treated as part of their trial.  This trial is continuing to enroll more people.  This is a intermediate report of progress.  I'm hoping there will be more information published at ADA or EASD, but this is from their press release.  Note that they are reporting on 12 patients (all treated, no untreated comparison group), and that 7 of the patients were in their honeymoon phase, and 5 were not.

The treatment has been very safe and well tolerated by all the study subjects. 

Six months following the initial screening four of the seven [honeymoon] patients showed increased C-peptide levels, whereas most Type 1 diabetics progressively lose their ability to produce endogenous insulin, and, therefore, demonstrate progressively decreasing levels of C-peptide. 

Three of the seven [honeymoon] patients displayed decreased dependence on insulin during the 3-6 month period following the start of their eight week AAT therapy.

My interpretations (opinions) of the results:

• They don't provide any numbers:  no c-peptide numbers and no insulin number.  I've come to believe this is a bad sign.  I hope they publish this data soon.
• For established type-1 diabetics, it looks like AAT had no positive effect at all, in this small sample. 
• For honeymoon type-1 diabetics, Omni is trying to be optimistic, and it does look like the treated group did better in some ways than average untreated people.  However, the reporting is vague, no numbers are provided, few patients were treated, and things are naturally unsettled in the honeymoon phase, that it is very hard to see the data described so far as a successful result.  So I would not get excited about AAT yet. 

Press Release: http://www.omnibiopharma.com/_literature_136822/Omni_Bio_Diabetes_Trial_Data_-_May_30,_2012

A Personal Note

Several months ago my wife and I started looking for a new house.  That takes a lot of time, and actually buying one, even more so.  I'm happy to say that we were successful, and are in the middle of moving from one Silicon Valley town to another.  That is why I have not had the time to publish any blogs for a while.  It now looks like I will move into the new house in mid-June  (wooo-hooo!).  I hope to return to my normal blogging sometime in late July or August.

I know there are more things going on in the world of research aimed at curing type-1 diabetes than I have included in this blog, and I'm sorry it will take a while to get through the backlog.  I'm sure there will be a land side of new information from the upcoming scientific conferences, as well.

Joshua Levy
All the views expressed here are those of Joshua Levy, and nothing here is official JDRF or JDCA news, views, policies or opinions. My blog contains a more complete non-conflict of interest statement. 
Clinical Trials Blog: http://cureresearch4type1diabetes.blogspot.com
Cured in Mice Blog: http://t1dcuredinmice.blogspot.com/