CADASIL

Hugues Chabriat*, Anne Joutel*, Martin Dichgans*, Elizabeth Tournier-Lasserve, Marie Germaine Bousser

Treatment
At present, there is no treatment of proven efficacy for CADASIL, either for the disease or for the main symptoms. Treatment is thus entirely pragmatic.

Lancet Neurol 2009; 8:643-53

CADASIL Potential therapeutic avenues?

Anne JOUTEL Mark NELSON

Disease-modifying treatments based on understanding the pathogenic sequence

Stroke cognitive $ motor disability

Migraine with aura

White matter changes

Notch3 ECD/ GOM deposits

~10

~20

~30

~40

~50

~60

~70yrs old

Notch3ECD-directed therapeutic approach for CADASIL

Notch3ECD cascade hypothesis Possible therapeutic interventions: Reducing Notch3 production, Preventing Notch3ECD aggregation, Facilitating Notch3ECD clearance Therapeutic window depends on the scenario: (1) Notch3ECD trigger (2) Notch3ECD threshold or (3) Notch3ECD driver scenario > duration and cost of the treatment Notch3ECD irrelevant scenario

Antisense oligonucleotides (ASOs) to reducing the concentration of proteins

Short synthetic chemically modified nucleic acids that bind RNA target Gene silencing (degradation) or modulation of RNA metabolism (splicing) Nonselective (WT &mutant alleles) or mutant allele-specific silencing
From Southwell et al, Trends in Molecular Medicine 2012

Antisense oligonucleotides (ASOs) therapeutics for inherited brain diseases

Favorable characteristics
Long tissue half-life of chemically modified (backbone structure or sugar ring ) ASOs (~28 days) Efficient CNS delivery by intrathecal infusion into the CSF

Efficient uptake in neurons and glia (SMC??)

Nuclear entry Naked ASOs > greater tolerance and precise dosing

Successful preclinical studies (Huntingtons disease and ALS) Beneficial effect may persist for longer than target suppression > transient therapy A phase 1 first-in-man well-tolerated study (SOD1-ALS) (phase 2 in TTRamyloidosis)

Antisense oligonucleotides therapeutics for CADASIL?

Reduce expression of all Notch3ECD toxic species Nonselective silencing easier but safety of WT Notch3 suppression in the adult ? (adverse effects on the microcirculation) Allele-specific muNotch3? SMC uptake? Need to set up in vitro cellular assays, humanized mouse models (nonhuman primate models) to screen and test ASO By how much should Notch3ECD production be lowered ? ? Therapeutic window

The anti-A immunotherapy in Alzheimers disease: 14 years of experience

Amyloid cascade hypothesis (toxicity of soluble, oligomeric and fibrillar A species) Passive (Anti-A antibodies administration) / active (A immunization to induce anti-A immune response) Attenuates A deposition and facilitates clearance of A aggregates in mouse models and patients with Alzheimers disease Total CNS exposure of anti-A antibodies depends on fractional CNS penetrance (0.05-0.2%) + CNS half life (0.5-4 hours)+ cycling between CNS and plasma+ plasma half life (1-3 weeks)+ bioavailability Mechanisms of passive immunization are multiple but controversial (peripheral sink, Fc-mediated phagocytosis by microglia, monomer neutralization, Ab-mediated disruption of aggregates.. )

The challenge of anti-A immunotherapy adverse effects

Aseptic meningoencephalitis

Active

Passive immunization

From Liu, Y.-H. et al., Nat. Rev. Neurol. 2012

The failures of phase III antibody trials in Alzheimers disease - Future directions
Reasons for failure
Given too late Participants without abnormal amyloid burden by PET scanning (~30%) Mixed nature of dementia Insufficient dosing and duration ? Treatment against other targets needed

Future directions
Secondary prevention studies: (1-API) 300 presymptomatic PS1 mutation carriers from a large colombian family, (2-DIAN) presymptomatic carriers of PS1, PS2 or APP mutations , (3-ADCS) 1000 65-85 yo cognitively normal subjects with amyloid + PET New trial designs (adaptative and targeted designs)

Anti-Notch3ECD immunotherapy for CADASIL ?

Extracellular Notch3ECD deposits Possibility to monitor Notch3ECD deposits in alive mice and patients (peripheral vessels) Proof-of-concept study of the Notch3ECD cascade hypothesis

?? soluble Notch3ECD in the CSF and plasma ? Exacerbate deposits, vessel wall inflammation upon treatment ? Phagocytosis by microglia of perivascular deposits ? deleterious effect on WT Notch3 function (cerebral and peripheral vessels) ? Therapeutic window ( scenarios)

Boosting the glymphatic clearance of Notch3ECD?

From Ilif et al, Sci Transl Med 2012

Restoring the neurovascular dysfunction in CADASIL?

Relationship between cerebrovascular function and brain lesions? Pharmacology of Kv channels-Not good. Ideal approach would be to restore normal levels of the appropriate Kv (1.5) channel only in the brain vasculature

A promising avenue to improve the predictive value of mouse models for clinical trials
Internal validity
Randomization Gender and genetic background Sample size and statistics Blinded evaluation Health status of mice Flow of animals through an experiment

Construct validity: models predict what they model

Matching model to human manifestations of the disease Matching outcome measures to clinical setting

External validity
Replication in different models of the same disease Independent replication

Conclusion

CADASIL, good candidate disease for ASO or immunotherapy

Optimal treatment= combination of treatments > need to pursue Research

Advance into human testing preclinical candidates that have demonstrated benefits in animal models with very few adverse effects upon prolonged dosing

Align the design of preclinical studies with subsequent human clinical trial design (critical issue is when to intervene, determine the therapeutic window)
Preventive trials > need for reliable outcome measures at the pre and early symptomatic stage in patients