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Successful Application of Patient Reported Outcome in Multiple Sclerosis Andrew R. Blight, Ph.D. Chief Scientific Officer Acorda Therapeutics, Inc. Hawthorne, NY RARE DISEASE WORKSHOP SERIES Improving the Clinical Development Process June 15, 2011
Dalfampridine USAN (generic) name of 4-aminopyridine (4-AP) Blocks voltage-dependent K + channels AMPYRA (Dalfampridine extended-release tablets) approved by FDA in Jan 2010 indicated to improve walking in patients with multiple sclerosis (MS). This was demonstrated by an increase in walking speed.
The Measurement Problem We want to determine whether a treatment has a meaningful beneficial effect on a temporally variable symptom of disease We expect the treatment to change neurological function but it is only important if (downstream, with the addition of many other variables) it makes a difference in the patient s life How much functional change is clinically relevant? Only a subset of patients is expected to be biologically susceptible to treatment benefit Mean changes in the whole treatment group may (grossly) underestimate the treatment effect size in those who actually benefit
Adapted from Kurtzke. Neurology. 1983;33:1444. Progression of Disability in MS
Timed 25-Foot Walk
Independent Studies Report a 20% Change in Timed 25FT Walk to be Clinically Relevant T25FW varied by <20% on repeated testing 1, thus >20% change is considered a real change 1,2 Worsening of >20% was perceived as increased disability in daily life by MS patients, using a Patient Reported Outcome measure 3,4 Improvement of >20% was reflected in subjective improvement by patients 5 1. Schwid Neurology 2002; 58:1294-1296 2. Kaufman Mult Scler 2000; 6: 286-290.5. van Winsen Mult Scler 2010; 14 (5) 604-6 3. Hoogervorst Mult Scler 2004; 10: 55-60 4. Kragt Mult Scler 2006; 12: 594-598
MSWS-12 Questionnaire Over the last 2 weeks, how much has your MS: 1. Limited your ability to walk? 2. Limited your ability to run? 3. Limited your ability to climb up and down stairs? 4. Made standing when doing things more difficult? 5. Limited your balance when standing or walking? 6. Limited how far you are able to walk? 7. Increased the effort needed for you to walk? 8. Made it necessary for you to use support when walking indoors? 9. Made it necessary for you to use support when walking outdoors? 10. Slowed down your walking? 11. Affected how smoothly you walk? 12. Made you concentrate on your walking?
Patient Reported Impact of Walking Disability: 12-item MS Walking Scale (MSWS-12) 1 Developed from qualitative research with people with MS to define the important aspects of walking from the patient s perspective Defines walking function and quality through 12 different rated aspects Scientifically strong measurement properties supported by multiple studies independent of dalfampridine development 1-3 MSWS-12 complements T25FW as it measures a different aspect of walking (disability vs. speed) from a different perspective (subjective vs. objective) As such, the correlations between these two endpoints are expected to be, and found to be, moderate 1. Hobart Neurology 2003 2. Motl Res Nurs Health 2008 3. McGuigan Neurology 2004
Phase 3 Trials Overview Studies MS-F203 and MS-F204 Conducted under Special Protocol Assessments (SPA) Primary outcome Consistent improvement in walking speed on Timed 25-foot Walk ( Timed Walk Response ) Additional requirement in MS-F203 MSWS-12* improvement among TW Responders, to show that the response criterion is clinically relevant *12-Item MS Walking Scale
Why Responder Analysis? Correspondence to clinical practice and clinical experience Allows effect size to be examined in the individuals who actually benefit Consistent with expected biological mechanism May facilitate regulatory judgment
An Unusual Response Criterion Responder analyses depend on a defining criterion for response This criterion is usually designed: To identify differences of meaningful magnitude (i.e. a worthwhile change from the expected) Not to identify a causal relationship between treatment and effect (i.e. a true response ) If we are unsure of what is meaningful, we can try to identify related changes and then determine if they are meaningful to patients
Study MS-F203 Overall Design Trial 1 Design Screening Visit Dalfampridine-ER 10 mg b.i.d. Follow-up Visits (3:1 randomization) placebo 2 week placebo run-in 14-week stable dose 1.Goodman AD et al. Lancet. 2009;373:732 738.
Primary Endpoint Response Criterion A Timed Walk Responder is a subject whose walking speed on at least 3 of the 4 on-drug visits is faster than the fastest speed during any of 5 off-drug visits 5 Off-drug Visits 4 On-drug Visits
Timed Walk Response Criterion Designed to identify treatment-related changes, for a true separation of treatment responders and non-responders Not based on an arbitrarily selected threshold of clinical significance Threshold for response varies with the baseline variability of the individual subject Additional characterization of Timed Walk Responders within the studies was required by protocol to show associated change in patient reported disability (MSWS-12 score) 15
Significant Increase in Timed Walk Response with Dalfampridine Percent Timed Walk Responders MS-F203 MS-F204 50 P < 0.001 50 50 P < 0.001 42.9 40 30 34.8 40 40 30 30 20 10 8.3 20 20 10 10 9.3 0 Placebo (N = 72) Dalfamp 10 mg (N = 224) 0 0 Placebo Placebo (N=118) (N = 118) AMPYRA (N = 119) 10 mg (N=119) Dalfamp 10 mg Goodman AD et al. Lancet. 2009;373:732 738. Goodman AD et al. Ann. Neurol. 2010; 68:494 502.
Decrease in Self-Assessed Walking Disability Among Timed Walk Responders Protocol Specified Analysis of Correlation Change in MSWS-12 from Baseline 1 0-1 -2-3 -4-5 -6-7 MS-F203 MS-F204 12-Item MS Walking Scale 12-Item MS Walking Scale ITT Population ITT Population p = 0.0002 Change in MSWS-12 from Baseline 1 0-1 -2-3 -4-5 -6-7 p = 0.0001-8 Timed Walk Non-Responders (n = 212) Timed Walk Responders (N = 84) -8 Timed Walk Non-Responders (n = 175) Timed Walk Responders (N = 62)
MSWS-12 Score: Treatment Effect Driven by Responder Group Treatment Group analysis Responder analysis Mean ± SEM N=190 N=343 P=0.004 N=129 N=214 MS-F203 and MS-F204, pooled MSWS-12=12-item Multiple Sclerosis Walking Scale; SEM=standard error of the mean
~ 20% Change in T25FW (still!) Appears to be a Clinically Relevant Threshold* 5 0 Improvement Average Change in MSWS-12-5 -10-15 -20-25 <0% (N=125) 0% (N=408) 10% (N=253) 20% (N=138) 30% (N=61) 40% (N=28) 50% (N=12) 60% (N=7) Relative Change in Walking Speed on the T25FW *MS-F203 and MS-F204 combined data (placebo and dalfampridine) Hobart Mult Scler 2010(Suppl)
Population Analysis 50 40 Change in Walking Speed (%) 30 20 10 0-10 -20-30 -40-50 Active Drug TW Responder (N=129) Active Drug TW Non-responder (N=214) Placebo (N=190) 0 10 20 30 40 50 60 70 80 90 100 Percentile Rank Timed Walk Nonresponders show distribution of changes similar to placebo patients *Pooled data (MS-F203 MS-F204)
How Real is Responder Status?* First Exposure Second Exposure Off treatment *Pooled data from MS-F203, MS-F204, MS-F203EXT and MS-F204 EXT
*Ampyra Prescribing Information But What Resonates?*
Summary Consistency of change on a quantitative measure can be an effective way to identify response to treatment A patient-reported outcome can support the clinical relevance of a change in a functional measure It remains easier to understand the notion of response measured by a given magnitude of change from a supposed baseline in the whole treatment group This comfort may be illusory