Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration ISSN: 2167-8421 (Print) 2167-9223 (Online) Journal homepage: https://www.tandfonline.com/loi/iafd20 Masitinib as an add-on therapy to riluzole in patients with amyotrophic lateral sclerosis: a randomized clinical trial Jesus S. Mora, Angela Genge, Adriano Chio, Conrado J. Estol, Delia Chaverri, Maria Hernández, Saúl Marín, Javier Mascias, Gabriel E. Rodriguez, Monica Povedano, Andrés Paipa, Raul Dominguez, Josep Gamez, Maria Salvado, Christian Lunetta, Carlos Ballario, Nilo Riva, Jessica Mandrioli, Alain Moussy, Jean-Pierre Kinet, Christian Auclair, Patrice Dubreuil, Vincent Arnold, Colin D. Mansfield, Olivier Hermine & on behalf of the AB10015 STUDY GROUP To cite this article: Jesus S. Mora, Angela Genge, Adriano Chio, Conrado J. Estol, Delia Chaverri, Maria Hernández, Saúl Marín, Javier Mascias, Gabriel E. Rodriguez, Monica Povedano, Andrés Paipa, Raul Dominguez, Josep Gamez, Maria Salvado, Christian Lunetta, Carlos Ballario, Nilo Riva, Jessica Mandrioli, Alain Moussy, Jean-Pierre Kinet, Christian Auclair, Patrice Dubreuil, Vincent Arnold, Colin D. Mansfield, Olivier Hermine & on behalf of the AB10015 STUDY GROUP (2020) Masitinib as an add-on therapy to riluzole in patients with amyotrophic lateral sclerosis: a randomized clinical trial, Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, 21:1-2, 5-14, DOI: 10.1080/21678421.2019.1632346 To link to this article: https://doi.org/10.1080/21678421.2019.1632346 © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. View supplementary material Published online: 07 Jul 2019. Submit your article to this journal Article views: 7943 View related articles View Crossmark data Citing articles: 27 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iafd20 Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, 2020; 21: 5–14 RESEARCH ARTICLE Masitinib as an add-on therapy to riluzole in patients with amyotrophic lateral sclerosis: a randomized clinical trial JESUS S. MORA1, ANGELA GENGE2, ADRIANO CHIO3 , CONRADO J. ESTOL4, DELIA CHAVERRI5, MARIA HERNÁNDEZ5, SAÚL MARÍN5, JAVIER MASCIAS5, GABRIEL E. RODRIGUEZ6, MONICA POVEDANO7, ANDRÉS PAIPA7, RAUL DOMINGUEZ7, JOSEP GAMEZ8 , MARIA SALVADO8, CHRISTIAN LUNETTA9, CARLOS BALLARIO10, NILO RIVA11, JESSICA MANDRIOLI12, ALAIN MOUSSY13, JEAN-PIERRE KINET13,14, CHRISTIAN AUCLAIR13,15, PATRICE DUBREUIL13,16, VINCENT ARNOLD13, COLIN D. MANSFIELD13, OLIVIER HERMINE13,17 AND ON BEHALF OF THE AB10015 STUDY GROUP 1 ALS Unit, Hospital San Rafael, Madrid, Spain; 2Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada; 3Department of Neuroscience, University of Turin, Turin, Italy; 4Neurological Center for Treatment and Rehabilitation, Buenos Aires, Argentina; 5Department of Neurology, ALS Unit, Hospital Carlos III, Madrid, Spain; 6Neurology Department, Neuron Motor Disease Clinic, Hospital JM Ramos, Buenos Aires, Argentina; 7Neurology Department, Bellvitge Hospital-IDIBELL, Barcelona, Spain; 8Neurology Department, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain; 9NEMO Clinical Centre, Serena Onlus Foundation, Milan, Italy; 10Neurorosario, Rosario, Argentina; 11Department of Neurology-INSPE, San Raffaele Scientific Institute, Milan, Italy; 12Department of Neurosciences, St. Agostino-Estense Hospital, Azienda Ospedaliero Universitaria di Modena, Modena, Italy; 13AB Science, Paris, France; 14Department of Pathology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, USA; 15Department of Biology, Universite Paris Sud Universite Paris-Saclay CNRS UMR 8113, Ecole Normale Superieure de Cachan, Cachan, France; 16INSERM, CNRS, Institut Paoli-Calmettes, CRCM, Centre de Reference des Mastocytoses, Equipe Labelisee Ligue Nationale Contre le Cancer, Aix-Marseille University, Marseille, France; and 17Imagine Institute, INSERM UMR 1163 and CNRS ERL 8254, Laboratory of Cellular and Molecular Mechanisms of Hemathological Disorders and Therapeutic Implication, H^opital Necker, Paris, France Abstract Objective: To assess masitinib in the treatment of ALS. Methods: Double-blind study, randomly assigning 394 patients (1:1:1) to receive riluzole (100 mg/d) plus placebo or masitinib at 4.5 or 3.0 mg/kg/d. Following a blinded transition from phase 2 to phase 2/3, a prospectively defined two-tiered design was implemented based on ALSFRS-R progression rate from disease-onset to baseline (DFS). This approach selects a more homogeneous primary efficacy population (“Normal Progressors”, DFS < 1.1 points/month) while concurrently permitting secondary assessment of the broader population. Primary endpoint was decline in ALSFRS-R at week-48 (DALSFRS-R), with the high-dose “Normal Progressor” cohort being the prospectively declared primary efficacy population. Missing data were imputed via last observation carried forward (LOCF) methodology with sensitivity analyses performed to test robustness. Results: For the primary efficacy population, masitinib (n ¼ 99) showed significant benefit over placebo (n ¼ 102) with a DALSFRS-R between-group difference (DLSM) of 3.4 (95% CI 0.65–6.13; p ¼ 0.016), corresponding to a 27% slowing in rate of functional decline (LOCF methodology). Sensitivity analyses were all convergent, including the conservative multiple imputation technique of FCS-REGPMM with a DLSM of 3.4 (95% CI 0.53–6.33; p ¼ 0.020). Secondary endpoints (ALSAQ-40, FVC, and time-to-event analysis) were also significant. Conversely, no significant treatment-effect Correspondence: Jesus S. Mora, M.D., ALS Unit, Unidad de ELA, Hospital San Rafael, c/Serrano, 199, Madrid 28016, Spain. Email: sanrafael.neurociencias@hsjd.es AB10015 STUDY GROUP collaborators (non-author investigators) listed in Supplementary Table 1. Supplemental data for this article can be accessed here. (Received 23 December 2018; revised 10 May 2019; accepted 4 June 2019) ISSN 2167-8421 print/ISSN 2167-9223 online ß 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. DOI: 10.1080/21678421.2019.1632346 6 J. S. Mora et al. according to DALSFRS-R was seen for the broader “Normal and Fast Progressor” masitinib 4.5 mg/kg/d cohort, or either of the low-dose (masitinib 3.0 mg/kg/d) cohorts. Rates of treatment-emergent adverse events (AEs) (regardless of causality or post-onset DFS) were 88% with masitinib 4.5 mg/kg/d, 85% with 3.0 mg/kg/d, and 79% with placebo. Likewise, rates of serious AE were 31, 23, and 18%, respectively. No distinct event contributed to the higher rate observed for masitinib and no deaths were related to masitinib. Conclusions: Results show that masitinib at 4.5 mg/kg/d can benefit patients with ALS. A confirmatory phase 3 study will be initiated to substantiate these data. Keywords: Clinical trials, therapy, tyrosine kinase inhibitor, masitinib Introduction toxicity according to predefined criteria. The study protocol and amendments were approved by the Amyotrophic lateral sclerosis (ALS) is character- institutional review board or ethics committee at ized by the progressive loss of motor neurons in each participating clinical site and was conducted the brain and spinal cord leading to a deterioration in accordance with the Declaration of Helsinki. All of muscle strength with subsequent wasting, par- patients provided written informed consent. This alysis, and loss of motor functions such as speech, trial was registered at www.clinicaltrials.gov as # swallowing, and breathing. Respiratory failure usu- NCT02588677). ally leads to death about 4 years after onset, Protocol amendments were implemented dur- although life expectancy is highly variable suggest- ing the study with data remaining blinded through- ing heterogeneity in the physiopathology of motor out, i.e. no changes were data-driven. There were neuron loss (1,2). Worldwide prevalence of ALS is two key amendments: a non-premeditated passage currently estimated at 235,000 with a projected from a phase 2 to a demonstrative phase 2/3 69% increase by the year 2040 (1). Despite signifi- design, requiring appropriate adjustment in sample cant effort, the overwhelming majority of clinical size and statistical hypothesis (first amendment trials have failed to demonstrate efficacy, highlight- dated 02 July 2013 following recruitment of 34/ ing an urgent unmet medical need (3,4). Riluzole, 394 (9%) patients, of which none had completed a glutamate antagonist, is the only widely available the 48-week treatment period); and implementa- disease modifying drug for ALS patients, although tion of a prospectively tiered design based on its benefits are a very modest increase in survival, aggressiveness phenotype (third amendment dated with no improvement in quality-of-life or slowing 08 October 2014 following recruitment of 142/394 of functional loss. Intravenous edaravone, a free (36%) patients, of which 46/394 (12%) had com- radical scavenger, recently received approval by the pleted the 48-week treatment period). This latter US Food and Drug Administration (5,6). amendment involved categorization of patients Masitinib, an oral tyrosine kinase inhibitor, has according to Amyotrophic Lateral Sclerosis demonstrated promising preclinical activity in ALS Functional Rating Scale-Revised (ALSFRS-R) (SOD1G93A) rat models, exerting neuroprotection progression rate (DFS) (15–18), calculated from via its immunomodulatory properties and in par- disease-onset to baseline with a dichotomizing cut- ticular through targeting microglia, macrophage off at 1.1 points/month. Accordingly, patients and mast cell activity, in both central and periph- receiving masitinib 4.5 mg/kg/d with post-onset eral nervous systems (7–9). Here, we report find- DFS < 1.1 points/month (referred to hereafter as ings from study AB10015, evaluating the efficacy “Normal Progressors” and comprising an esti- and safety of masitinib in ALS patients. mated 84% of the ALS population) were prede- fined as the primary efficacy population. All Methods necessary information was available from patient records, meaning no retrospective data-collection Study design and oversight was necessary, with stratification (minimization Study AB10015 was an international, multicenter, algorithm) implemented for the remaining (64%) phase 2/3, randomized, double-blind, placebo- patient recruitment to ensure balanced treatment- controlled trial over a 48-week treatment period. It arms. This prospectively defined two-tiered commenced in April 2013 and was completed in approach defines a more homogenous target popu- December 2016. Patients were randomly assigned lation (primary analysis), reducing variability and (1:1:1) to receive riluzole (100 mg/d) plus placebo therefore sample size requirements, while concur- or masitinib at 4.5 or 3.0 mg/kg/d (bis in die), with rently permitting evaluation (secondary analysis) of the high-dose cohort being predefined for primary the broader, more heterogeneous population. The analysis. Masitinib dose was chosen based on pre- rationale for this amendment (detailed in the clinical data (unpublished) and accumulated clin- Supplementary Information, eDiscussion Section ical experience for masitinib in non-oncology A), assumed that heterogeneity in ALS disease indications (10–14). Dose reduction or treatment aggressiveness reflects differing disease mecha- interruption was allowed for moderate or severe nisms, with dysregulated immunity being one Masitinib for the treatment of amyotrophic lateral sclerosis 7 possibly factor (19), leading to an unpredictable death. Exploratory analysis included assessment in and likely divergent treatment-effect across the cohorts with less severe symptoms at baseline. overall population. Furthermore, the right-skewed Patients were monitored for safety or toxicity (positive-skew) characteristic of DFS histogram until 28 d after discontinuing study drug. Adverse distributions was a common observation in clinical events (AE) and laboratory values (hematology, practice (20). This indicates that while a majority blood biochemistry, and urinalysis) were classified of patients fall within a fairly narrow range of post- and graded according to Common Terminology onset DFS (e.g. 0.1–1.1 points/month), more rap- Criteria for Adverse Events version 4 (Bethesda, idly progressing patients present with a far wider MD). Safety analysis was reported regardless of range and are therefore a greater source of DFS causality, according to dose and patient cohort. An heterogeneity between treatment-arms. independent Data Safety Monitoring Committee monitored safety throughout the study. Patients Statistical analysis Eligible patients were aged 18–75 years with a laboratory-supported probable, probable, or defin- Patients were randomized using a computerized ite diagnosis of ALS (revised El Escorial criteria) central randomization system and minimization (21,22), had less than 36 months duration of dis- method according to the covariates (i.e. prognostic ease from the first ALS symptom (i.e. any progres- factors) of site of onset (spinal versus bulbar), sive focal weakness or atrophy) and forced vital ALSFRS-R score, age, geographical region, and capacity (FVC) of at least 60% at baseline. post-onset DFS (as per the aforementioned proto- Additionally, patients were receiving a stable dose col amendment). In this manner, the difference of riluzole (100 mg/d) for at least 30 d prior to among treatment groups, with respect to prognos- baseline. Patients were ineligible if presenting with tic factors, was minimized (Table 1). The safety gastrostomy, dementia, significant organ or system dataset comprised all patients that received at least dysfunction, cancer, or uncontrolled medical con- one dose of study medication, while the efficacy dition that might interfere with trial results, and dataset also required patients to have received at previous treatment with any investigational agent least one intake of study medication and have at within 3 months prior to baseline. least one post-baseline efficacy assessment. Consistent with common practice, any patient Study measurements dying after randomization had an ALSFRS-R score of zero imputed. All main, sensitivity, and sub- The primary endpoint was decline in ALSFRS-R group analyses reported herein were pre-specified from baseline to week-48 (DALSFRS-R), with in the study’s statistical analysis plan prior to assessments performed at weeks 4, 8, 12, and unblinding unless stated otherwise. every 12 weeks thereafter. Missing data were To detect a 3.3-point difference (standard devi- imputed via last observation carried forward ation of 7.5 points assumed) in DALSFRS-R (LOCF) methodology for those patients discontin- between masitinib and placebo (corresponding to uing because of toxicity or lack of efficacy before an approximate 30% improvement in the rate of week 48. Several predefined sensitivity analyses ALSFRS-R decline), with a two-sided 5% signifi- were performed to test robustness of the primary cance level and a power of 80% in the Normal analysis result, including full analysis dataset (non- Progressor population, a sample size of 300 LOCF) imputation methods and variations on patients (100 in each treatment-arm, incorporating LOCF via censoring on reason for discontinu- a 5% margin) was necessary. Likewise, for the ation. Additional sensitivity analyses included the broader population analysis (i.e. Normal and Fast conservative techniques of multiple imputation, Progressors), an estimated 381 patients (127 per jump-to-reference, and tipping-point analysis (see treatment-arm) were required to detect a 3.3-point Supplementary eDiscussion Section B for detailed difference (standard deviation of 9.0 points description). assumed). DALSFRS-R was calculated using a Predefined secondary analyses included assess- model of analysis of covariance (ANCOVA), ment of the broader “Normal and Fast Progressor” adjusted on the aforementioned baseline covariates, masitinib 4.5 mg/kg/d cohort, and corresponding expressing results as difference of least-squares DFS-tiered low-dose (masitinib 3.0 mg/kg/d) means (DLSM) between treatments (masitinib ver- cohorts. Secondary endpoints included change from sus placebo) with corresponding 95% two-sided baseline in ALS Assessment Questionnaire 40-item confidence intervals (CI) and statistical test p value (ALSAQ-40) score (23), FVC, overall survival obtained via a re-randomization test (10,000 repli- (OS), and time-to-event analysis (an endpoint cate). Secondary endpoints were similarly analyzed driven by both death and a fixed disease progres- using ANCOVA or Kaplan–Meier methods. sion on the ALSFRS-R scale) (24,25), defined here One planned interim analysis was performed as a deterioration of 9 points from baseline or (cutoff date 22 February 2016) after 50% of 8 J. S. Mora et al. Table 1. Baseline patient characteristics according to the ITT dataset (N ¼ 394). Treatment-arms were well balanced for all baseline parameters. Normal progressor dataseta Normal & fast progressor datasetb PBO M4.5 M3.0 PBO M4.5 M3.0 (n 5 114) (n 5 106) (n 5 110) (n 5 133) (n 5 130) (n 5 131) Demographic Gender (male) (n, %) 69 (60.5%) 69 (65.1%) 70 (63.6%) 80 (60.2%) 83 (63.8%) 81 (61.8%) Age (years) 55.4 ± 10.5 54.8 ± 10.8 54.9 ± 10.3 55.2 ± 10.6 55.5 ± 10.6 55.7 ± 10.2 (Mean ± SD) Age (range) 27.0 ; 75.0 24.0 ; 79.0 33.0 ; 75.0 27.0 ; 75.0 24.0 ; 79.0 33.0 ; 75.0 Site of onset Spinal (n, %) 90 (78.9%) 85 (80.2%) 92 (83.6%) 109 (82.0%) 107 (82.3%) 110 (84.0%) Bulbar (n, %) 24 (21.1%) 21 (19.8%) 18 (16.4%) 24 (18.0%) 23 (17.7%) 21 (16.0%) BMI (median) [18.5 BMI <25] 22.8 23.4 23.5 22.5 23.4 23.4 [25 BMI 35] 28.0 27.6 28.0 28.1 27.6 28.0 ALS diagnosisc Definite (n, %) 66 (57.9%) 64 (60.4%) 60 (54.5%) 79 (59.4%) 76 (58.5%) 73 (55.7%) Probable (n, %) 38 (33.3%) 33 (31.1%) 37 (33.6%) 43 (32.3%) 44 (33.8%) 43 (32.8%) Probable, laboratory-supported (n, %) 10 (8.8%) 9 (8.5%) 13 (11.8%) 11 (8.3%) 10 (7.7%) 15 (11.5%) Disease durationd From diagnosis (months) (Mean ± SD) 9.7 ± 7.3 10.9 ± 8.7 10.7 ± 7.6 9.1 ± 7.0 9.7 ± 8.4 10.0 ± 7.4 From first symptom 19.5 ± 8.4 21.6 ± 8.9 20.7 ± 8.0 18.1 ± 8.6 19.2 ± 9.6 19.2 ± 8.2 Post-onset DFS a “Normal Progressors” (n, %) 114 (100%) 106 (100%) 110 (100%) 114 (85.7%) 106 (81.5%) 110 (84.0%) Mean ± SD (points/month) 0.49 ± 0.24 0.49 ± 0.25 0.48 ± 0.25 0.71 ± 0.69 0.73 ± 0.63 0.65 ± 0.48 Range (points/month) 0.05 ; 1.07 0.03 ; 1.08 0.09 ; 1.07 0.05 ; 5.00 0.03 ; 3.69 0.09 ; 2.24 ALSFRS-R score Mean ± SD 39.3 ± 4.6 38.3 ± 5.3 38.6 ± 5.1 38.1 ± 5.5 37.5 ± 5.5 37.4 ± 5.7 Range 27.0 ; 47.0 23.0 ; 47.0 23.0 ; 46.0 21.0 ; 47.0 23.0 ; 47.0 21.0 ; 46.0 FVC (% predicted) Mean ± SD 90.3 ± 19.0 89.0 ± 16.5 88.1 ± 18.9 89.2 ± 18.7 87.5 ± 16.9 86.8 ± 18.7 Range 37.0 ; 136.0 60.0 ; 131.0 51.0 ; 149.0 37.0 ; 136.0 45.0 ; 131.0 51.0 ; 149.0 ALSAQ-40 score Mean ± SD 30.2 ± 14.0 32.7 ± 15.2 33.0 ± 16.1 33.0 ± 15.8 35.6 ± 16.4 35.8 ± 17.4 Range 3.1 ; 70.6 6.3 ; 74.4 3.1 ; 68.1 3.1 ; 74.4 6.3 ; 78.1 3.1 ; 80.6 Region Western Europe & N America 72 (63.2%) 61 (57.5%) 68 (61.8%) 86 (64.7%) 81 (62.3%) 84 (64.1%) Eastern Europe 8 (7.0%) 8 (7.5%) 5 (4.5%) 8 (6.0%) 8 (6.2%) 5 (3.8%) Latin America 34 (29.8%) 37 (34.9%) 37 (33.6%) 39 (29.3%) 41 (31.5%) 42 (32.1%) Country Spain 39 (34.2%) 38 (35.8%) 40 (36.4%) 51 (38.3%) 53 (40.8%) 51 (38.9%) Argentina 33 (28.9%) 36 (34.0%) 36 (32.7%) 38 (28.6%) 40 (30.8%) 41 (31.3%) Italy 26 (22.8%) 16 (15.1%) 22 (20.0%) 28 (21.1%) 21 (16.2%) 26 (19.8%) Slovakia 6 (5.3%) 4 (3.8%) 3 (2.7%) 6 (4.5%) 4 (3.1%) 3 (2.3%) Netherlands 3 (2.6%) 4 (3.8%) 2 (1.8%) 3 (2.3%) 4 (3.1%) 3 (2.3%) Canada 4 (3.5%) 1 (0.9%) 3 (2.7%) 4 (3.0%) 1 (0.8%) 3 (2.3%) Greece 2 (1.8%) 4 (3.8%) 2 (1.8%) 2 (1.5%) 4 (3.1%) 2 (1.5%) Portugal 0 (0.0%) 2 (1.9%) 1 (0.9%) 0 (0.0%) 2 (1.5%) 1 (0.8%) Mexico 1 (0.9%) 1 (0.9%) 1 (0.9%) 1 (0.8%) 1 (0.8%) 1 (0.8%) a “Normal Progressor” dataset defined as patients with a post-onset DFS of less than 1.1 points/month. b “Normal and Fast Progressor” dataset includes all patients, regardless of the post-onset DFS selection criterion. DFS ¼ ALSFRS-R progression rate from disease-onset to baseline. ALSFRS-R ¼ Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised. “Normal and Fast Progressor” dataset is closely matched to the Safety (SAF) population. PBO ¼ Placebo plus riluzole. M4.5 ¼ Masitinib 4.5 mg/kg/day plus riluzole. M3.0 ¼ Masitinib 3.0 mg/kg/day plus riluzole. BMI: body mass index (kg/m2); ALSAQ-40 ¼ ALS Assessment Questionnaire 40-item. c ALS diagnosis according to revised El Escorial criteria. d Disease duration calculated from the first ALS symptom (i.e. any progressive focal weakness or atrophy) to baseline, or from time of diagnosis to baseline. FVC: forced vital capacity; SD: standard deviation randomized patients could have reached the 48- population had been randomized prior to interim week timepoint. Consistent with predefined rules readout it was recommended to continue the and justified considering the urgent unmet medical blinded study without further amendment until final need in ALS, positive interim results led to an early readout, thereby providing fully developed evidence regulatory submission. Because the full study and supportive follow-up analysis for the positive Masitinib for the treatment of amyotrophic lateral sclerosis 9 interim result. Consequently, all tests reported analysis outcome (see Supplementary eDiscussion herein are performed at a significance level of 5%. Section B). Considering the FCS-REGPMM (Fully Conditional Specification Regression Predictive Mean Matching) method, modeled on factors hav- Results ing maximum impact on variability of ALSFRS, Patients DLSM was 3.4 (95% CI 0.53–6.33; p ¼ 0.020). Between April 2013 and December 2015, a total of Secondary efficacy analyses 394 patients underwent randomization from 34 sites in 9 countries. Three patients were excluded for effi- Significance on DALSFRS-R was not reached for cacy analysis due to lack of post-baseline efficacy the secondary analysis populations of the “Normal assessment or no drug intake, yielding a dataset of and Fast Progressor” masitinib 4.5 mg/kg/d cohort 391 patients: 132, 131, and 128 patients in the pla- (which showed a DLSM of 2.09 in favor of masiti- cebo, masitinib 3.0 mg/kg/d, and masitinib 4.5 mg/ nib, p ¼ 0.12), or either of the low-dose (masitinib kg/d treatment-arms, respectively (Figure 1). The 3.0 mg/kg/d) cohorts (Supplementary eTable 4). primary efficacy population (i.e. “Normal The observed significant treatment-effect for Progressors” receiving masitinib 4.5 mg/kg/d versus “Normal Progressors” receiving masitinib 4.5 mg/ placebo) comprised 105 and 113 patients, respect- kg/d (primary efficacy population) was however sup- ively, of which 99 and 102 patients were assessable ported by positive benefit in various secondary end- for the primary endpoint, as determined by prede- points (Table 2 and Supplementary eFigure 1). fined data imputation rules (see Supplementary Patients on masitinib showed a significantly lower eDiscussion Section B). The number of patients dis- deterioration in quality-of-life, as measured by the continuing during the 48-week treatment period ALSAQ-40 scale, with a between-group difference was about 34% in both treatment-arms. of 29% (DLSM change of 19.42 versus 27.18; Randomized patients were well-balanced between p ¼ 0.008). For respiratory function, as measured treatment-arms regarding proportion of patients by FVC, patients on masitinib showed a signifi- completing the 48-week treatment period (Figure 1) cantly lower deterioration with a between-group and on all baseline parameters (including demo- difference of 22% (DLSM change of 26.45 graphics, site of onset, disease duration, DFS, distri- versus  33.99; p ¼ 0.03). Time-to-event analysis bution of slower progressive patients, baseline showed patients on masitinib had a significant 25% scores, and geographical region) (Table 1 and delay in disease progression (20 versus 16 months, Supplementary eTable 2). p ¼ 0.016) (Supplementary eFigure 2). Conversely, there was no discernible difference in overall sur- Primary efficacy analysis vival (OS) with median OS not being reached in either the masitinib (4.5 mg/kg/d) or placebo treat- For the primary efficacy population, DALSFRS-R ment-arms. showed a significant benefit for masitinib over pla- cebo with a between-group difference in Subgroup analysis DALSFRS-R of 3.39 (9.24 versus  12.63); 95% CI 0.65–6.13, p ¼ 0.016 (Table 2 and Subgroup analyses explored whether patient response Supplementary eFigure 1). This represents a clin- to masitinib was influenced by baseline disease sever- ically meaningful 27% slowing of ALSFRS-R ity, as determined by ALSFRS-R individual compo- deterioration over the 48-week treatment period. nent scores, e.g. exclusion of patients with zero- All predefined sensitivity analyses on the pri- point ALSFRS-R items at randomization. Results mary endpoint were statistically significant (see showed that initiation of masitinib (4.5 mg/kg/d) at Supplementary eDiscussion Section B and a less severe stage of disease produced greater treat- eTable 3). Considering the most pessimistic full ment-effect according to DALSFRS-R and time-to- analysis dataset (imputation with penalty), which event analysis. This included a significant benefit in estimates progression for similarly clustered the broader “Normal and Fast Progressor” cohort patients then imputes missing values using this (Supplementary eDiscussion Section C). average trend, DALSFRS-R for masitinib (n ¼ 104) Safety was 11.4 versus 14.4 for placebo (n ¼ 111); corresponding to a DLSM of 3.0 and significant A summary of safety results during the 48-week 26% slowing in rate of decline (p ¼ 0.018). treatment period, regardless of causality, is pre- Additional sensitivity analyses were performed sented in Table 3. Generally, patients receiving using the recommended techniques of multiple masitinib at 4.5 mg/kg/d (M4.5) reported higher imputation, jump-to-reference, and tipping-point. rates of AE, severe AE and serious AE than Results from these analyses were all significant patients receiving masitinib at 3.0 mg/kg/d (M3.0) (p ¼ 0.048, p ¼ 0.039, and a 77% penalty, respect- or placebo, which were similar. Considering the ively) and convergent with the positive primary overall safety dataset (n ¼ 393), rates of 10 J. S. Mora et al. Figure 1. Patient flow diagram, detailing patient disposition for the ITT, assessable safety, assessable efficacy, primary efficacy, and secondary efficacy populations. Primary efficacy population prospectively defined as “Normal Progressor” patients (pts) receiving masitinib at 4.5 mg/kg/d versus placebo. “Normal Progressor” dataset defined as patients with a post-onset DFS of less than 1.1 points/ month. DFS ¼ ALSFRS-R progression rate from disease-onset to baseline. ALSFRS-R ¼ Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised. ITT ¼ intention-to-treat population. PBO ¼ Placebo plus riluzole. M4.5 ¼ Masitinib 4.5 mg/kg/d plus riluzole. M3.0 ¼ Masitinib 3.0 mg/kg/d plus riluzole. Secondary efficacy populations include the “Normal and Fast Progressor” masitinib 4.5 mg/ kg/d cohort and DFS-tiered low-dose (masitinib 3.0 mg/kg/d) cohorts. “Normal and Fast Progressor” dataset includes all patients, regardless of the post-onset DFS selection criterion. FP ¼ “Fast Progressor” patients (defined as post-onset DFS 1.1 points/month). † Primary endpoint ¼ change in ALSFRS-R from baseline to week-48. Assessable patients for primary endpoint according to rule 1 for missing data imputation, i.e. last observation carried forward methodology for those patients discontinuing because of toxicity or lack of efficacy before week 48 (see Supplementary eDiscussion B for detailed description of rules). discontinuation resulting from AE were 16.3, 16.0, placebo were maculopapular rash and peripheral and 9.0% in the M4.5 (n ¼ 129), M3.0 (n ¼ 131), edema (Table 4). Overall rates of serious AE were and placebo (n ¼ 133) treatment-arms, respect- 31% with M4.5, 23% with M3.0, and 18% with ively. Among 33 patients who died while on-treat- placebo. Overall rates of severe AE (grade 3/4) ment or 28 d after discontinuing treatment, 10 were 29% with M4.5, 22% with M3.0, and 17% (8%), 11 (8%), and 12 (9%) were from the M4.5, with placebo. One isolated case (0.8%) of auto- M3.0, and placebo treatment-arms, respectively immune-like hepatitis was reported in the M4.5 (Table 3). No death was related to treatment-arm, with the patient showing increased study treatment. liver transaminase levels (grade 3) at week-24 (26). Rates of AE (any grade) were 88% with M4.5, This resolved after masitinib was discontinued and 85% with M3.0, and 79% with placebo. The only a combination of prednisone and azathioprine was AEs occurring at least 5% more frequently for started. Three other cases of increased transami- masitinib (regardless of dose) compared with nases were reported (2 patients on M4.5 and 1 Masitinib for the treatment of amyotrophic lateral sclerosis 11 Table 2. Results summary for the primary efficacy population of “Normal Progressor” patients receiving masitinib 4.5 mg/kg/d versus placebo. nd LSM DLSM [95% CI] p Value a ALSFRS-R PBO 102 12.6 3.4 [0.7 ; 6.1] 0.016e M4.5 99 9.2 b ALSAQ-40 PBO 102 27.2 7.8 [13.5 ; -2.1] 0.008 M4.5 99 19.4 b FVC PBO 102 34.0 7.5 [0.8 ; 14.3] 0.03 M4.5 98 26.5 b,c TIME-TO-EVENT – – Median [95% CI] p Value PBO 113 – 16 months [11;19] 0.016 M4.5 105 – 20 months [14;30] “Normal Progressor” dataset defined as post-onset DFS <1.1 points/month. DFS ¼ ALSFRS-R progression rate from disease-onset. ALSFRS-R ¼ Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised. a Primary endpoint. b Secondary endpoint. c Time-to-event analysis defined as time interval (months) for ALSFRS-R deterioration of 9 points from baseline or death. d The primary efficacy population (“Normal Progressors” receiving masitinib 4.5 mg/kg/d versus placebo) comprised 105 and 113 patients, respectively, of which 99 and 102 patients were assessable for the primary endpoint, as determined by the predefined rule 1 for missing data imputation (see Supplementary eDiscussion Section B for detailed description of rules). e p Value obtained via a re-randomization test. LSM ¼ Least-squares means difference from baseline. DLSM ¼ Between treatment-arm difference of LSM. 95% two-sided confidence intervals [95% CI]. PBO ¼ Placebo plus riluzole. M4.5 ¼ Masitinib 4.5 mg/kg/d plus riluzole. ALSAQ-40 ¼ ALS Assessment Questionnaire. FVC: forced vital capacity Table 3. Safety summary over the 48-week treatment period according to dose and patient cohort (safety dataset, regardless of causality)a. Number (%) of patients with at least one PBO (n 5 133) M4.5 (n 5 129) D[M4.5] (%) M3.0 (n 5 131) D[M3.0] (%) AE (any grade) 105 (78.9%) 114 (88.4%) 9.4 111 (84.7%) 5.8 Severe AE (grade 3/4) 22 (16.5%) 38 (29.5%) 12.9 29 (22.1%) 5.6 Non-fatal serious AE 24 (18.0%) 40 (31.0%) 13.0 30 (22.9%) 4.9 AE leading to deathb 12 (9.0%) 10 (7.8%) 1.3 11 (8.4%) 0.6 AE leading to permanent discontinuationc 12 (9.0%) 21 (16.3%) 7.3 21 (16.0%) 7.0 AE leading to temporarily interruption 2 (1.5%) 16 (12.4%) 10.9 3 (2.3%) 0.8 AE leading to dose reduction 14 (10.5%) 43 (33.3%) 22.8 23 (17.6%) 7.0 a Adverse events (AE) were recorded until 28 d after treatment interruption with any AE not resolved at the death of the patients recorded as an AE leading to death. Safety dataset excluded 1 patient from ITT because of no intake of study drug. PBO ¼ Placebo plus riluzole. M4.5 ¼ Masitinib 4.5 mg/kg/day plus riluzole. D[M4.5] ¼ difference between M4.5 and placebo treatment-arms (M4.5 minus PBO). M3.0 ¼ Masitinib 3.0 mg/kg/d plus riluzole. D[M3.0] ¼ difference between M3.0 and placebo treatment-arms (M3.0 minus PBO). b No deaths were considered related to study treatment (masitinib or riluzole). c AE leading to permanent discontinuation excluding death. patient on M3.0), all of which were non-severe the study’s predefined primary efficacy population, cases that resolved without sequelae following tem- exceeding the clinically meaningful target of slowing porary treatment interruption or premature discon- ALSFRS-R decline by 20% (27). Exploratory sub- tinuation as per protocol safety rules. group analyses indicated further improvement is possible when initiating treatment at a less severe stage of disease (e.g. exclusion of patients with zero- Discussion point ALSFRS-R items at baseline). Secondary end- While patients receiving masitinib at 4.5 mg/kg/d points also showed significant improvement in terms as an add-on therapy to riluzole experienced more of quality-of-life (ALSAQ40), respiratory function frequent SAE and severe AE with respect to pla- (FVC), and time-delay in ALSFRS-R deterioration cebo, no distinct event contributed to these higher or death (time-to-event analysis). rates (see Supplementary eTables 6 and 7, respect- An innovative feature of this study design was ively). No new safety concerns were identified for the use of DFS to ensure a more homogeneous pri- masitinib, findings being consistent with masiti- mary efficacy population, thereby potentially miti- nib’s known risk profile (12–14). Masitinib showed gating the risk of divergent treatment-effect across significant benefit in DALSFRS-R over placebo for the overall population and reducing required 12 J. S. Mora et al. Table 4. Most frequent adverse events for masitinib treatment relative to placebo over the 48-week treatment period according to dose and patient cohort (safety dataset, regardless of severity or causality, listed as per MedDRA preferred terms)a. Number (%) of patients with at PBO M4.5 M3.0 MALL least one (n 5 133) (%) (n 5 129) (%) D[M4.5] (%) (n 5 131) (%) D[M3.0] (%) (n 5 260) (%) D[MALL] (%) Rash maculo papular 1 (0.8) 11 (8.5) 7.7 6 (4.6) 3.8 17 (6.5) 5.8 Nausea 6 (4.5) 15 (11.6) 7.1 8 (6.1) 1.6 23 (8.8) 4.3 Respiratory failure 5 (3.8) 13 (10.1) 6.3 9 (6.9) 3.1 22 (8.5) 4.7 Edema peripheral 1 (0.8) 9 (7.0) 6.2 7 (5.3) 4.5 16 (6.2) 5.4 Iron deficiency anemia 2 (1.5) 9 (7.0) 5.5 3 (2.3) 0.8 12 (4.6) 3.1 Dyspnoea 3 (2.3) 10 (7.8) 5.5 3 (2.3) 0.0 13 (5.0) 2.7 Anxiety 1 (0.8) 8 (6.2) 5.4 5 (3.8) 3.0 13 (5.0) 4.2 Weight decreased 9 (6.8) 14 (10.9) 4.1 13 (9.9) 3.1 27 (10.4) 3.6 (loss) Dyspepsia (indigestion) 4 (3.0) 9 (7.0) 4.0 3 (2.3) 0.7 12 (4.6) 1.6 Diarrhea 5 (3.8) 10 (7.8) 4.0 11 (8.4) 4.6 21 (8.1) 4.3 Fall 7 (5.3) 12 (9.3) 4.0 9 (6.9) 1.6 21 (8.1) 2.8 Abdominal pain upper 3 (2.3) 8 (6.2) 3.9 4 (3.1) 0.8 12 (4.6) 2.4 Blood bilirubin 1 (0.8) 6 (4.7) 3.9 0 (0.0) 0.8 6 (2.3) 1.6 increased Rash 6 (4.5) 10 (7.8) 3.3 3 (2.3) 2.2 13 (5.0) 0.5 Constipation 2 (1.5) 6 (4.7) 3.2 2 (1.5) 0.0 8 (3.1) 1.6 Cystitis bacterial 2 (1.5) 6 (4.7) 3.2 3 (2.3) 0.8 9 (3.5) 2.0 Urinary tract infection 2 (1.5) 6 (4.7) 3.2 5 (3.8) 2.3 11 (4.2) 2.7 Eyelid edema 0 (0.0) 4 (3.1) 3.1 0 (0.0) 0.0 4 (1.5) 1.5 Upper respiratory tract 1 (0.8) 5 (3.9) 3.1 2 (1.5) 0.7 7 (2.7) 1.9 infection Cough 3 (2.3) 7 (5.4) 3.1 0 (0.0) 2.3 7 (2.7) 0.4 Rash generalized 0 (0.0) 4 (3.1) 3.1 1 (0.8) 0.8 5 (1.9) 1.9 a Adverse events (AE) listed in order of greatest positive difference between M4.5 and placebo treatment-arms (M4.5 minus PBO). AEs described using MedDRA preferred terms. Any given AE can be listed under multiple MedDRA preferred terms, which are not therefore cumulative. Safety dataset excluded 1 patient from ITT because of no intake of study drug. PBO ¼ Placebo plus riluzole. M4.5 ¼ Masitinib 4.5 mg/kg/d plus riluzole. D[M4.5] ¼ difference between M4.5 and placebo treatment-arms (M4.5 minus PBO). M3.0 ¼ Masitinib 3.0 mg/kg/day plus riluzole. D[M3.0] ¼ difference between M3.0 and placebo treatment-arms (M3.0 minus PBO). MALL ¼ pooled M4.5 and M3.0. D[MALL] ¼ difference between MALL and placebo arm (MALL minus PBO). AEs were recorded until 28 d after treatment interruption. sample size. Sensitivity analyses showed that the indicates that “Fast Progressors” (i.e. post-onset dichotomizing cutoff of 1.1 points/month was well- DFS 1.1 points/month) are less susceptible to judged and associated with a sizeable “buffer masitinib at the doses tested. One speculative zone” for maintained significant treatment-effect explanation could be that these patients are experi- (see Supplementary eDiscussion Section A). This encing a more aggressive form of ALS with rapid highlights that it is the action of dichotomization loss of motor neurons requiring earlier interven- itself, and subsequent improved sample homogen- tion. Additional disease mechanisms offer another eity, that is of key importance and not optimiza- explanation for relative lack of efficacy in “Fast tion of a specific cutoff value. Progressor” patients, with targeted therapies One possible issue for interpretation of results expected to work on only a subset of ALS patients. was the use of LOCF methodology in the primary Indeed, gene expression profiling and proteomic analysis. This concern was mitigated through studies in ALS have successfully differentiated numerous and diverse sensitivity analyses, which patients with rapid and non-rapid progressive dis- together corroborate the robustness of the primary ease (the latter defined as having an equivalent analysis and provide reassurance that the observed DFS of around 1.0 point/month) (19,28–31), such treatment-effect was not driven by possible LOCF evidence supporting the premise that these groups bias (see Supplementary eDiscussion Section B). represent pathophysiologically distinct forms Protocol amendments made during the study also of ALS. represent a challenge for interpretation of results; Finally, the reduced treatment-effect observed in particular the transition to phase 2/3, albeit that for low-dose cohorts suggests dose-dependency, this change occurred with data remaining blinded with the starting dose of 3.0 mg/kg/d being too low and prior to any of the patients having reached the to show significant improvement in DALSFRS-R 48-week timepoint. over placebo at the current sample size (p value The reduced treatment-effect observed in the was 0.0661). This suggests that patients could pos- “Normal and Fast Progressor” cohort possibly sibly benefit from receiving a higher masitinib Masitinib for the treatment of amyotrophic lateral sclerosis 13 dose, any risk of increased toxicities being mitigated double-blind, placebo-controlled trial. Lancet Neurol. via implementation of a dose-escalation scheme as 2017;16:30115–1. 6. Hardiman O, van den Berg LH. Edaravone: a new previously described in the literature (14). treatment for ALS on the horizon? Lancet Neurol. 2017; In conclusion, study AB10015 represents the 16:490–1. first successful randomized, controlled, phase 2/3 7. Trias E, Ibarburu S, Barreto-N ~ ez R, Babdor J, Maciel un trial in ALS of a tyrosine kinase inhibitor. Results TT, Guillo M, et al. Post-paralysis tyrosine kinase show that masitinib at 4.5 mg/kg/d can benefit inhibition with masitinib abrogates neuroinflammation and slows disease progression in inherited amyotrophic lateral patients with ALS. A confirmatory phase 3 study sclerosis. J Neuroinflammation. 2016;13:177. will be initiated to confirm these findings. 8. Trias E, Ibarburu S, Barreto-N ~ ez R, Varela V ,Moura un IC, Dubreuil P, et al. Evidence for mast cells contributing to neuromuscular pathology in an inherited model of ALS. Acknowledgments JCI Insight. 2017;2:e95934. 9. Trias E, King PH, Si Y, Kwon Y, Varela V, Ibarburu S, We thank the study participants, their families, and et al. Mast cells and neutrophils mediate peripheral motor caregivers. We also thank the AB10015 Study pathway degeneration in ALS. JCI Insight. 2018;3:pii: Group collaborators (Supplementary eTable 1). The 123249. Spanish ALS Research Foundation, FUNDELA, 10. Dubreuil P, Letard S, Ciufolini M, Gros L, Humbert M, Casteran N, et al. Masitinib (AB1010), a potent and contributed to Dr. Mora’s group support. selective tyrosine kinase inhibitor targeting KIT. PLoS One. 2009;4:e7258. Declaration of interest 11. Davis MI, Hunt JP, Herrgard S, Ciceri P, Wodicka LM, Pallares G, et al. Comprehensive analysis of kinase Masitinib is under clinical development by the inhibitor selectivity. Nat Biotechnol. 2011;29:1046–51. study funder, AB Science. AM, CDM, and VA are 12. Vermersch P, Benrabah R, Schmidt N, Zephir H, Clavelou P, Vongsouthi C, et al. Masitinib treatment in employees and shareholders of AB Science. OH is patients with progressive multiple sclerosis: a randomized the President of the Scientific Committee of AB pilot study. BMC Neurol. 2012;12:36. Science. PD, CA, and J-PK are consultants and 13. Piette F, Belmin J, Vincent H, Schmidt N, Pariel S, Verny shareholders of AB Science. JSM and AG have M, et al. Masitinib as an adjunct therapy for mild-to- moderate Alzheimer’s disease: a randomised, placebo- received research funding from AB Science. All controlled phase 2 trial. Alzheimers Res Ther. 2011;3:16. remaining authors have no competing interests. 14. Lortholary O, Chandesris MO, Livideanu CB, Paul C, Guillet G, Jassem E, et al. Masitinib for treatment of severely symptomatic indolent systemic mastocytosis: a randomised, Funding placebo-controlled, phase 3 study. Lancet. 2017;389:612–20. Financial support for medical editorial assistance 15. Labra J, Menon P, Byth K, Morrison S, Vucic S. Rate of disease progression: a prognostic biomarker in ALS. J was provided by AB Science. Neurol Neurosurg Psychiatry. 2016;87:628–32. 16. Kimura F, Fujimura C, Ishida S, Nakajima H, Furutama D, Uehara H, et al. Progression rate of ALSFRS-R at time ORCID of diagnosis predicts survival time in ALS. Neurology. Adriano Chio http://orcid.org/0000-0001- 2006;66:265–7. 17. Gordon PH, Cheung YK, Kimura F. Progression rate of 9579-5341 ALSFRS-R at time of diagnosis predicts survival time in Josep Gamez http://orcid.org/0000-0003- ALS. Neurology. 2006;67:1314–5. 3127-7486 18. Kollewe K, Mauss U, Krampfl K, Petri S, Dengler R, Mohammadi B. ALSFRS-R score and its ratio: a useful predictor for ALS-progression. J Neurol Sci. 2008;275:69–73. References 19. Henkel JS, Beers DR, Wen S, Rivera AL, Toennis KM, Appel JE, et al. Regulatory T-lymphocytes mediate 1. Arthur KC, Calvo A, Price TR, Geiger JT, Chi o A, amyotrophic lateral sclerosis progression and survival. Traynor BJ. Projected increase in amyotrophic lateral EMBO Mol Med. 2013;5:64–79. sclerosis from 2015 to 2040. Nat Commun. 2016;7: 20. Proudfoot M, Jones A, Talbot K, Al-Chalabi A, Turner 12408. MR. The ALSFRS as an outcome measure in therapeutic 2. van Es MA, Hardiman O, Chio A, Al-Chalabi A, trials and its relationship to symptom onset. Amyotroph Pasterkamp RJ, Veldink JH, et al. Amyotrophic lateral Lateral Scler Frontotemporal Degener. 2016;17:414–25. sclerosis. Lancet. 2017;390:2084–98. 21. Brooks BR. El Escorial world federation of neurology 3. Beghi E, Chi o A, Couratier P, Esteban J, Hardiman O, criteria for the diagnosis of amyotrophic lateral sclerosis. Logroscino G, et al. The epidemiology and treatment of Subcommittee on Motor neuron diseases/Amyotrophic ALS: focus on the heterogeneity of the disease and critical lateral sclerosis of the world federation of neurology appraisal of therapeutic trials. Amyotroph Lateral Scler. research group on neuromuscular diseases and the El 2011;12:1–10. Escorial ’Clinical limits of amyotrophic lateral sclerosis’ 4. Petrov D, Mansfield C, Moussy A, Hermine O. ALS workshop contributors. J Neurol Sci. 1994;124:96–107. clinical trials review: 20 years of failure. Are we any closer 22. Brooks BR, Miller RG, Swash M, Munsat TL. El Escorial to registering a new treatment? Front Aging Neurosci. revisited: revised criteria for the diagnosis of amyotrophic 2017;9:68. lateral sclerosis. Amyotroph Lateral Scler Other Motor 5. Writing Group; Edaravone (MCI-186) ALS 19 Study Neuron Disord. 2000;1:293–9. Group. Safety and efficacy of edaravone in well defined 23. Jenkinson C, Fitzpatrick R, Brennan C, Swash M. patients with amyotrophic lateral sclerosis: a randomised, Evidence for the validity and reliability of the ALS 14 J. S. Mora et al. assessment questionnaire: the ALSAQ-40. Amyotroph decline in ALSFRS-R. Amyotroph Lateral Scler. 2010;11: Lateral Scler Other Motor Neuron Disord. 1999;1:33–40. 178–80. 24. Committee for Medicinal Products for Human Use 28. Cooper-Knock J, Green C, Altschuler G, Wei W, Bury JJ, (CHMP). Guideline on clinical investigation of medicinal Heath PR, et al. A data-driven approach links microglia to products for the treatment of amyotrophic lateral sclerosis pathology and prognosis in amyotrophic lateral sclerosis. (ALS) EMA/CHMP/40105/2013. London: European Acta Neuropathol Commun. 2017;5:23. Medicines Agency; 2015. 29. Zhao W, Beers DR, Hooten KG, Sieglaff DH, Zhang A, 25. Aggarwal SP, Zinman L, Simpson E, McKinley J, Jackson Kalyana-Sundaram S, et al. Characterization of gene KE, Pinto H, et al. Safety and efficacy of lithium in expression phenotype in amyotrophic lateral sclerosis combination with riluzole for treatment of amyotrophic monocytes. JAMA Neurol. 2017;74:677–85. lateral sclerosis: a randomised, double-blind, placebo- 30. Beers DR, Zhao W, Wang J, Zhang X, Wen S, Neal D, controlled trial. Lancet Neurol. 2010;9:481–8. et al. ALS patients’ regulatory T lymphocytes are 26. Salvado M, Vargas V, Vidal M, Simon TM, Camacho J, dysfunctional, and correlate with disease progression rate Gamez J. Autoimmune-like hepatitis during masitinib and severity. JCI Insight. 2017;2:e89530. therapy in an amyotrophic lateral sclerosis patient. World J 31. Murdock BJ, Zhou T, Kashlan SR, Little RJ, Goutman Gastroenterol. 2015;21:10475–9. SA, Feldman EL. Correlation of peripheral immunity with 27. Castrillo-Viguera C, Grasso DL, Simpson E, Shefner J, rapid amyotrophic lateral sclerosis progression. JAMA Cudkowicz ME. Clinical significance in the change of Neurol. 2017;74:1446–54.