TauRx Parses Subgroups to Make the Case for Methylene Blue Derivative, Again
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Old drugs die hard. Despite a string of negative Phase 3 trials, HMTM, a derivative of the malaria drug methylene blue, resurfaced again at AD/PD 2024, held March 5-9 in Lisbon, Portugal. TauRx CEO Claude Wischik reported results from exploratory and post hoc analyses, as well as from an open-label extension, of the Lucidity trial, which evaluated HMTM in people with MCI and mild to moderate AD. As had been reported previously, the trial failed to meet its co-primary endpoints. At the meeting, Wischik reported that over the yearlong trial, participants with MCI who took the highest dose of the drug were half as likely to progress to AD as were volunteers in the control group. Among a subset of participants for whom blood samples were available, the drug also appeared to stem a small rise in plasma neurofilament light—a marker of neurodegeneration, he said. Further, in the open-label extension, participants with MCI who received the drug all along declined more slowly than those who had previously been in the control group, the company claimed. Given the troubled past of TauRx trials, many scientists who spoke with Alzforum were reticent to weigh in on the latest presentations of the data. Those who did were not convinced by the various subgroup analyses or, in a new twist for methylene blue trials, comparisons to external, historical controls. “Overall, there continues to be no evidence that these methylene blue derivatives have biomarker or clinical efficacy in Alzheimer’s disease,” wrote Lawrence Honig of Columbia University in New York (comment below).
- In Phase 3, HMTM failed to meet co-primary endpoints.
- Subgroup analysis of an open-label extension suggests benefit in people with MCI.
- In that subgroup, half as many people transitioned to AD.
- HMTM may curb a teeny rise in plasma NfL, at least among participants with MCI.
Lucidity and its predecessors have been marred with complications, mostly wrought by the lack of a true control group. Because the compound gives urine a greenish-blue tinge, TauRx gave control volunteers just enough of the drug, or of a related compound, called MTC, to pee blue, to maintain blinding. Issues with this emerged in 2016, which saw HMTM, also known as LMTM, fail to slow cognitive decline in three Phase 3 trials—two in AD and one in FTD. Much to the chagrin of clinicians at the time, TauRx identified glimmers of hope within controversial subgroup analyses. They claimed that the treatment and placebo arms declined equally because the supposedly inactive placebo—8 mg/day of the drug versus 75 mg or 125 mg twice per day in treatment arms—was actually active. They also used subgroup analyses to claim that results were skewed by participants taking acetylcholine esterase inhibitors or memantine, and that in the 15 percent of people not taking those medication, LMTM slowed cognitive decline (Jul 2016 conference news; Dec 2016 conference news). They subsequently reported that HMTM boosts acetylcholine in the brains of mice (Kondak et al., 2022). Other scientists noted that people who are not taking cholinesterase inhibitors (AChEIs) typically have less-advanced dementia and therefore decline more slowly than people taking these drugs, explaining the differences in rates of cognitive decline between the LMTM monotherapy group and placebos who were mostly taking AChEIs.
Undeterred, TauRx opted for a new trial, excluding people taking AChEIs, and using much lower doses of HMTM in the active treatment group. It began in 2018, and, after several major changes, including to inclusion criteria, outcome measures, and duration, the final version of the trial protocol was published in 2022 (Wischik et al., 2022). Lucidity enrolled 598 people with MCI due to AD, mild AD, or moderate AD, all of whom were amyloid-positive according to PET scans. The 266 participants randomized to the control group took 4 mg MTC—a compound that Wischik said has the same activity as HMTM—twice weekly to maintain urine discoloration, while 252 received 16 mg/day of HMTM. A group receiving 8 mg/day was included for comparison to past trials, but these 80 volunteers were not included in analysis of the co-primary endpoints—change in ADAS-Cog11 and ADCS-ADL23 over 52 weeks. Secondary endpoints included change in whole-brain volume, while exploratory endpoints included change in clinical dementia rating scale (CDR) analyzed by disease severity.
At AD/PD, Wischik said that plasma NfL was measured as a prespecified biomarker endpoint; however, this is not listed within the published protocol or on clinicaltrials.gov.
After completing the 12-month randomized portion of the trial, all participants were invited to join an open-label extension, in which they received 16 mg HMTM per day for an additional 12 months. Wischik reported that 21 percent of participants dropped out of the blinded portion of the trial. Of those who completed it, 95 percent joined the extension. The drug was safe and well-tolerated. As determined previously, there were no significant differences between treatment and control groups for either co-primary outcome over the first 12 months of the trial (image below).
No Benefit. On co-primary outcomes (two left graphs) and secondary outcome of whole-brain volume (right), there were no differences between controls and the 16 mg/day group during the 12-month randomized portion of the trial, nor during the 12-month open label extension. [Courtesy of TauRx.]
In Lisbon, Wischik presented findings from a post hoc analysis of only those participants with MCI, who made up just under half of the total enrollees. In these participants, both the control and 16 mg/day groups improved over baseline in the first six months, this time on the ADAS-Cog13 (image below). Wischik claimed that because it is more sensitive, the ADAS-Cog13 better suits MCI patients than does the ADAS-Cog11 that was stipulated as the primary endpoint. He attributed the improvement on the ADAS-Cog13 to a tau-independent, symptomatic effect, purportedly mediated by a rise in acetylcholine in the hippocampus.
At 12 months, among those with MCI, scores in the control group had started to worsen while those in the treatment group held steady. In the open-label extension, MCI participants who had previously received 16 mg/day held steady on the ADAS-Cog13 out to 18 months, before dropping back to their baseline scores at 24 months. Scores continued to worsen between 18 and 24 months in people who had previously been part of the control group (image below). Wischik interpreted this finding to suggest that the placebo dose conferred a brief symptomatic effect, and that by the time the participants switched to the 16mg/day dose, it was too late to change the course of disease.
MCI Alone. A post hoc subgroup analysis of participants with MCI over the randomized and open-label portions of the trial suggest a benefit on the ADAS-Cog13 (left) among those taking 16 mg/day HMTM the whole time. [Courtesy of TauRx.]
Curiously, per the ADCS-ADL23, only the control MCI group experienced an apparent functional boost, doing slightly better than baseline at six months, but at no other time point. For the 16 mg/day group there was no statistically significant change from baseline during the two years to the ed of the extension. No difference emerged at any time point between the placebo and treatment groups.
This post hoc MCI subgroup analysis also teased out an effect on brain atrophy, said Wischik. At the 18- and 24-month timepoints in the extension, less brain shrinkage occurred among those with the treatment group relative to placebo.
As part of an exploratory analysis of CDR scores broken down by AD severity at baseline, Wischik claimed a 48 percent reduction in transition from MCI to AD at 12 months. What is this based on? Essentially, of 79 controls with MCI, 20 progressed from a CDR 0.5 to 1. By comparison, of 63 people with MCI in the treatment group, eight progressed from MCI to AD over 12 months. Most AD trials now eschew the CDR for the CDR sum of boxes, a much more refined test, especially for people in early stages of dementia.
HMTM Halts NfL’s Rise?
Plasma NfL, widely used as a marker of neurodegeneration in the brain, was measured in approximately 70 percent of the trial cohort “with available samples suitable for analysis,” according to Wischik. He did not explain why some samples were unavailable. He did report that the biomarker’s rise, not its concentration, over the 12-month trial was curbed by 95 percent among 136 people in the 16 mg/day group relative to 157 controls. Essentially, plasma NfL had inched up by 3 pg/mL in controls, but stayed put among people in the treatment group. Separating by disease severity, the effect was only significant among people with MCI. Among these milder cases, NfL held steady in 55 people in 16 mg/day groups and among 22 people in the 8mg/day group, while it rose by 3pg/mL among 68 controls.
NfL Stabilized? Over the 12-month randomized portion of Lucidity, plasma NfL rose by about 3 pg/mL in controls (left bar), but not among the 16 mg HMTM per day group (right bar).
Henrik Zetterberg, University of Gothenburg in Sweden, told Alzforum that the NfL findings were interesting, and may indicate that neurodegeneration became less intense in the treatment group. He has reported plasma NfL levels of around 40 pg/mL in MCI, increasing by about 2.7 pg/mL per year (Mar 2017 news; May 2019 news). Wischik did not show the absolute NfL levels. He also reported that among people whose NfL increased least, fewer transitioned from MCI to AD.
Finally, he presented comparisons between the pooled, three arms of Lucidity (including the placebo group) with two cohorts of external, historical controls. When compared to ADNI volunteers who were matched by sex, age, baseline MMSE, ApoE genotype, and who were not taking acetylcholinesterase inhibitors or memantine, Lucidity participants declined less on the ADAS-Cog11 and preserved more brain volume between baseline and 24 months. Those with MCI who received 16 mg/day were 75 percent less likely to transition to AD over 12 months than matched ADNI MCI cases. Similar effects were found when “meta-analytic” MCI controls from multiple trials were used as the external comparator.
Honig was not convinced by the trial data or the post hoc historical comparisons. “This duality thus involved both declaring the per protocol ‘placebo control’ group to actually be an active ‘non-placebo’ group, and using historical controls to imply efficacy in what was otherwise a negative randomized controlled trial,” he wrote.
Lon Schneider, University of Southern California, Los Angeles, was similarly incredulous. “Many pharmas—not having significant clinical outcomes from their randomized trials—just go on to find subsets and compare their outcomes to old data or ADNI instead of proper controls,” he wrote. “It’s a can’t-miss strategy that is sure to hack a p-value. We should do better in reporting trials results, and am confident we will in the future,” he wrote.
Although all of the apparent benefits of HMTM were found among exploratory endpoints, subgroup, or post hoc analyses, Wischik announced that TauRx will apply for marketing authorization for HMTM from the U.K.’s Medicines and Healthcare Products Regulatory Agency, and that discussions with the European Medicines Agency and Chinese regulators are moving forward as well.—Jessica Shugart
References
Therapeutics Citations
News Citations
- In First Phase 3 Trial, the Tau Drug LMTM Did Not Work. Period.
- Tau Inhibitor Fails Again—Subgroup Analysis Irks Clinicians at CTAD
- Blood Neurofilament Light a Promising Biomarker for Alzheimer’s?
- Plasma NfL Goes the Distance in Alzheimer’s
Paper Citations
- Kondak C, Riedel G, Harrington CR, Wischik CM, Klein J. Hydromethylthionine enhancement of central cholinergic signalling is blocked by rivastigmine and memantine. J Neurochem. 2022 Jan;160(2):172-184. Epub 2021 Dec 15 PubMed.
- Wischik CM, Bentham P, Gauthier S, Miller S, Kook K, Schelter BO. Oral Tau Aggregation Inhibitor for Alzheimer's Disease: Design, Progress and Basis for Selection of the 16 mg/day Dose in a Phase 3, Randomized, Placebo-Controlled Trial of Hydromethylthionine Mesylate. J Prev Alzheimers Dis. 2022;9(4):780-790. PubMed.
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Columbia University College of Physicians & Surgeons
The saga of “methylene blue,” or derivatives of this dye with various names, including LMT-X/LMTM and HMTM, continues with a presentation of TauRx-sponsored work at ADPD 2024. The history of this drug, which putatively targets tau aggregation at low doses and hippocampal acetylcholine levels at high doses, extends back over a decade.
Notably, in 2016 the first Phase 3 trial in AD of LMTM completely failed to show any benefit of the two “active” doses of 150 and 250 mg daily. With data presented at AAIC 2016 and published later that year, the investigators initially tried to snatch a small victory from the jaws of defeat by claiming a possible benefit for a small subset of patients (15 percent) taking no standard background AD therapies, by contortion comparing them to the larger, unmatched group of patients on placebo, some taking and some not taking standard AD therapies. Additional excuses for the failure of the drug followed, most notably that nonhuman studies now showed that the presumably inactive “placebo” comparator group, which contained 16 mg daily drug, was likely “active,” and, by such reassessment, explaining the absence of any drug-comparator benefit in the trial as a whole.
Since then, another Phase 3 trial, “LUCIDITY”, was performed with much smaller dose equivalents: two “active” doses of HMTM of 8 and 16 mg daily, and a “placebo” comparator dose of 4 mg MTC twice weekly (~1-2 mg daily equivalent of HMTM). The 12-month results were released in May 2022, and the 18-month results at CTAD2022, showing again no clinical efficacy of “active” dose groups versus comparator dose.
Now, 24-month results are released at ADPD 2024. The HMTM active dose groups show no efficacy versus the comparator “placebo” dose. But once again, it is argued that this is because the now very-very-low dose comparator group, equivalent to ~1-2 mg/day HMTM, is still also “active,” despite being proposed, per protocol, to not be “expected to have therapeutic clinical activity.” Despite this claim, an analysis of “as randomized,” rather than intent-to-treat, “active” groups was interpreted as variably showing marginally significant, or insignificant, lesser neurodegeneration by neurofilament light levels.
Various other Herculean analyses were performed to try to show benefit by comparing treatment arms to “matched” ADNI historical controls, suggesting that all three arms, including the “placebo,” did better on global (CDR progression), cognitive (ADAScog11), and whole-brain volume measures. This duality thus involved both declaring the per-protocol “placebo control” group to actually be an active “non-placebo” group, and using historical controls to imply efficacy in what was otherwise a negative randomized controlled trial. Overall, there continues to be no evidence that these methylene blue derivatives have biomarker or clinical efficacy in Alzheimer’s disease.
University of Southern California Keck School of Medicine
This may have been the fourth randomized Phase 3 trial of a form of methylene blue in various doses by this company. None was statistically significant compared to their contemporaneous controls. The trials used a small dose of HMTM or similar as the control so that all participants’ urine would be colored greenish-blue to help maintain the treatment blind. After one trial, the sponsor claimed that the inactive dose used for the control group was really a dose that should have been tested as a therapeutic dose, and that a yet lower dose should be used as the urine-dyeing control. They also thought that cholinesterase inhibitors masked clinical response to HMTM and should be excluded in order to draw out any therapeutic effect.
This LUCIDITY randomized controlled trial—MCI and AD, MMSE 16-27, Ab-PET positive, no cholinesterase inhibitors—fairly compared 16 mg/day of HMTM in 252 participants with 8 mg/week of HMTM as control in 266 people over 12 months. (There was also a small randomly assigned arm of 80 people given 8 mg/day that was meant for other purposes). The company reported selected, post hoc subset analyses at the ADPD 2024. The company’s main spin was to portray an MCI subset that received 12 months of HMTM 16 mg/day followed by a 12-month open-label treatment period as though it was 24 months of continuous treatment that showed a significant effect on the ADAS-cog13 compared to a subset that received 12 months of control dose, 8 mg/week, followed by 12 months of 16 mg/day. Note the ADAS-cog11 was the original primary outcome.
They go on to compare selected outcomes and subsets from the trial to selected ADNI clinical scores and to scores from placebo arms of previous AD trials, which they call “meta-analytic controls.” They arranged these displays on PowerPoints as though they are results from clinical trials. Never mind, that these are apples to oranges and historical comparisons. If you don’t read the fine print, you’d think that HMTM has about a 4- or 5-point advantage on the ADAS-cog11 after 18 or 24 months, with seemingly diverging slopes, supposedly indicating disease-modification, and that you pay a price for not treating early with HMTM. (NOT!)
We regularly see these types of presentations at meetings, often by sponsors. TauRx was a “gold” sponsor at ADPD 2024. Many pharmas—not having significant clinical outcomes from their randomized trials—just go on to find subsets and compare their outcomes to old data or ADNI instead of proper controls. It’s a can’t-miss strategy that’s sure to hack a p-value. We should do better in reporting trials results, and I am confident we will in the future.
Chair in Mental Health (Clin.), Aberdeen University
TauRx appreciates Alzforum’s coverage of the LUCIDITY trial and the opportunity to engage in constructive dialogue about its results. We seek to address inaccuracies and to help with understanding of the developmental history of the first tau aggregation inhibitor in late-stage development.
The commentary is premised on the expectation that there should be some straightforward way to demonstrate a treatment difference relative to a placebo control. The propensity of hydromethylthionine to produce green-blue urine coloration and the imperative to run blinded clinical trials has precluded the use of a true placebo in all but one of the trials. The fundamental challenge has been to maintain blinding without introducing confounding pharmacological activity. Despite this challenge, consistent treatment benefit on clinical decline and neuroimaging endpoints has been demonstrated in five large Phase 2 or 3 clinical trials. These results were primary prespecified outcomes in two of the trials, and came from post hoc subgroup analyses in the others,
A Phase 2 study using a true placebo identified methylthionine chloride (MTC) 138mg/day as the minimum effective dose, with significant positive effects on cognitive function as the primary prespecified cognitive outcome with similar effects on the prespecified neuroimaging endpoint (Wischik et al., 2015). MTC was subsequently found to have impaired bioavailability, a limitation overcome by hydromethylthionine mesylate (Baddeley et al., 2015). HMTM doses in the range 150-250 mg/day were compared with 8 mg/day in further Phase 3 trials, two in AD and one in FTD. hydromethylthionine 8 mg/day was found to produce plasma-concentration-dependent reduction in cognitive decline and brain shrinkage in all three trials (Schelter et al., 2019; Shiells et al., 2020). These effects were significant overall and in subjects receiving hydromethylthionine as add-on to standard symptomatic treatment. Even MTC, at the control dose of 8 mg/week in LUCIDITY, had symptomatic activity. Hydromethylthionine delivered by MTC was found to have atypical pharmacokinetics, with plasma concentration increasing over 12 months to levels at which MTC had been found to reverse scopolamine-induced cognitive impairment in a standard mouse model for symptomatic activity (Deiana et al., 2009).
The Alzforum report and its commentators take exception to the difference in outcomes between participants receiving HMTM as monotherapy and those receiving it as add-on to standard symptomatic treatments in the two earlier AD trials (Gauthier et al., 2016). The analyses for this difference were prespecified as modified primary outcomes in the second trial (Wilcock et al., 2018). These results are dismissed by arguing that patients receiving symptomatic treatments decline more rapidly than untreated patients. However, this more rapid decline is largely explainable by greater disease severity at the point of treatment initiation—this was corrected for in both trials. Furthermore, the difference in response to hydromethylthionine according to prior treatment has been reproduced in preclinical models (Riedel et al., 2000; Kondak et al., 2022). It is explained by brain homeostatic adaptations to chronic hyperstimulation produced by symptomatic treatments. The neuropharmacology of the brain’s response to hydromethylthionine differs according to prior treatment with symptomatic drugs.
In addition to confirming earlier evidence of clinically relevant and important therapeutic activity on reduction in clinical decline and brain shrinkage, LUCIDITY has also confirmed hydromethylthionine’s benign safety profile and tolerability. LUCIDITY provides statistically significant evidence of arrest of progression of neurodegeneration as measured by plasma levels of neurofilament light chain (NfL) in prespecified analyses in the as-randomised population with non-haemolysed plasma sample available in sufficient quantity. The NfL effect correlated with a similar effect on p-tau 181, and with measures of clinical decline and brain shrinkage. In mild cognitive impairment (MCI) there were significant differences in cognitive decline over 24 months according to initial treatment allocation. At 12 months the 16 mg/day dose reduced progression from MCI to AD from 25 percent in controls to 13 percent in those randomised to HMTM 16 mg/day, as measured by increase in the Clinical Dementia Rating from 0.5 to 1 or greater. Both values are substantially less than the conversion rate reported in amyloid-PET-positive MCI populations (47–82 percent).
If approved, hydromethylthionine could offer the prospect of a safe, oral, disease-modifying treatment for Alzheimer’s disease, which is readily accessible and which would represent an attractive option to offer to patients as part of the armamentarium of treatment approaches.
References:
Wischik CM, Staff RT, Wischik DJ, Bentham P, Murray AD, Storey JM, Kook KA, Harrington CR. Tau aggregation inhibitor therapy: an exploratory phase 2 study in mild or moderate Alzheimer's disease. J Alzheimers Dis. 2015;44(2):705-20. PubMed.
Baddeley TC, McCaffrey J, Storey JM, Cheung JK, Melis V, Horsley D, Harrington CR, Wischik CM. Complex disposition of methylthioninium redox forms determines efficacy in tau aggregation inhibitor therapy for Alzheimer's disease. J Pharmacol Exp Ther. 2015 Jan;352(1):110-8. Epub 2014 Oct 15 PubMed.
Schelter BO, Shiells H, Baddeley TC, Rubino CM, Ganesan H, Hammel J, Vuksanovic V, Staff RT, Murray AD, Bracoud L, Riedel G, Gauthier S, Jia J, Bentham P, Kook K, Storey JM, Harrington CR, Wischik CM. Concentration-Dependent Activity of Hydromethylthionine on Cognitive Decline and Brain Atrophy in Mild to Moderate Alzheimer's Disease. J Alzheimers Dis. 2019;72(3):931-946. PubMed.
Shiells H, Schelter BO, Bentham P, Baddeley TC, Rubino CM, Ganesan H, Hammel J, Vuksanovic V, Staff RT, Murray AD, Bracoud L, Wischik DJ, Riedel G, Gauthier S, Jia J, Moebius HJ, Hardlund J, Kipps CM, Kook K, Storey JM, Harrington CR, Wischik CM. Concentration-Dependent Activity of Hydromethylthionine on Clinical Decline and Brain Atrophy in a Randomized Controlled Trial in Behavioral Variant Frontotemporal Dementia. J Alzheimers Dis. 2020;75(2):501-519. PubMed.
Deiana S, Harrington CR, Wischik CM, Riedel G. Methylthioninium chloride reverses cognitive deficits induced by scopolamine: comparison with rivastigmine. Psychopharmacology (Berl). 2009 Jan;202(1-3):53-65. PubMed.
Gauthier S, Feldman HH, Schneider LS, Wilcock GK, Frisoni GB, Hardlund JH, Moebius HJ, Bentham P, Kook KA, Wischik DJ, Schelter BO, Davis CS, Staff RT, Bracoud L, Shamsi K, Storey JM, Harrington CR, Wischik CM. Efficacy and safety of tau-aggregation inhibitor therapy in patients with mild or moderate Alzheimer's disease: a randomised, controlled, double-blind, parallel-arm, phase 3 trial. Lancet. 2016 Dec 10;388(10062):2873-2884. Epub 2016 Nov 16 PubMed.
Wilcock GK, Gauthier S, Frisoni GB, Jia J, Hardlund JH, Moebius HJ, Bentham P, Kook KA, Schelter BO, Wischik DJ, Davis CS, Staff RT, Vuksanovic V, Ahearn T, Bracoud L, Shamsi K, Marek K, Seibyl J, Riedel G, Storey JM, Harrington CR, Wischik CM. Potential of Low Dose Leuco-Methylthioninium Bis(Hydromethanesulphonate) (LMTM) Monotherapy for Treatment of Mild Alzheimer's Disease: Cohort Analysis as Modified Primary Outcome in a Phase III Clinical Trial. J Alzheimers Dis. 2018;61(1):435-457. PubMed.
Riedel G, Klein J, Niewiadomska G, Kondak C, Schwab K, Lauer D, Magbagbeolu M, Steczkowska M, Zadrozny M, Wydrych M, Cranston A, Melis V, Santos RX, Theuring F, Harrington CR, Wischik CM. Mechanisms of Anticholinesterase Interference with Tau Aggregation Inhibitor Activity in a Tau-Transgenic Mouse Model. Curr Alzheimer Res. 2020;17(3):285-296. PubMed.
Kondak C, Riedel G, Harrington CR, Wischik CM, Klein J. Hydromethylthionine enhancement of central cholinergic signalling is blocked by rivastigmine and memantine. J Neurochem. 2022 Jan;160(2):172-184. Epub 2021 Dec 15 PubMed.
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