Patent Application
20170027990
The invention is concerned with a method of treating the mental state of patients with neurologic, functional, and/or motor deficits after ischemic stroke by intravenously administering allogeneic bone-marrow derived mesenchymal stem cells (itMSCs).
Neurodegenerative diseases are becoming more prevalent as the world's population ages. It has been estimated that by the year 2040, the number of people affected by a neurodegenerative disease will double to approximately 40 million people worldwide. In addition, this group of diseases is generally considered to be progressive and incurable, and currently have no approved treatment options that change the long-term prognosis or are curative. The three most prevalent chronic, age-related neurodegenerative diseases are Stroke, Parkinson's disease, and Alzheimer's disease, and there are currently significant research efforts focused on the prevention and treatment of these devastating neurodegenerative diseases that together create a vast global unmet medical need.
Stroke
Stroke remains a major global healthcare problem. Recent data compiled by the American Heart Association (AHA) for 2008 show that the annual incidence of new or recurrent stroke in the United States is about 780,000, with approximately 600,000 of these strokes being first attacks. Among adults age 20 and older, the estimated prevalence of stroke in 2005 was 5.8 million in the United States, resulting in >150,000 deaths annually, with 4.8 million stroke survivors alive today.1 Stroke ranks as the country's third leading cause of death, behind only cancer and heart disease. Stroke data indicates that the incidence may be increasing. From 1988 to 1997, the age-adjusted stroke hospitalization rate grew 18.6% (from 560 to 664 per 100 000), while total stroke hospitalizations increased 38.6% (from 592,811 to 821,760 annually).
Consistent with the pathophysiology and symptoms of stroke, stroke is a leading cause of adult impairment, with 20% of stroke survivors requiring institutional care after 3 months and up to 30% being severely and permanently disabled. The only approved treatments of acute ischemic stroke involve restoring blood flow to the affected region by using thrombolytics or mechanical devices that physically remove clots. However, the use of thrombolytics (tPA) is limited due to the therapeutic window of <3-6 hours post onset of stroke symptoms such that only a small fraction of stroke patients receive this therapy, thus effective prevention remains the best treatment for reducing the burden of stroke. Following the completion of a stroke, there is little therapy to offer patients to promote recovery other than physical, occupational, and speech therapy.
Stem Cells
Research efforts in the field of stem cell biology have accelerated and intensified during the last few decades and have provided important information on the developmental roles and pathophysiologic responses of stem cells. Stem cells can be found in many tissues (e.g., bone marrow, brain, adipose tissue, muscle, and eye) and can be isolated from many different tissue sources (e.g., embryo, fetus, placenta, umbilical cord blood). The advances in our understanding of stem cell biology have generated significant interest in the therapeutic potential of exogenous stem cell administration.
Allogeneic Mesenchymal Bone Marrow Cells (MSCs)
Mesenchymal stem cells have been isolated from a number of sources, including bone marrow, adipose tissue, peripheral blood, amniotic fluid, fetal liver, and umbilical cord blood. The MSCs manufactured for this study are a subset of non-hematopoietic stem cells derived from the bone marrow of healthy, adult donors, and have the ability to migrate and differentiate into multiple cell types depending on the local environment and extracellular matrix, and include cartilage, bone, adipose tissue, vasculature and neurons. As described below, the MSCs manufactured for this study were cultured and expanded in hypoxic (low-oxygen) conditions, referred to herein as ischemic tolerant mesenchymal stem cells, itMSCs. Several recent reports demonstrate that human MSCs derived from adult human bone marrow can differentiate in culture to neuronal stem cells that have all the neuroectodermal markers appropriate for this lineage, including nestin and otxl.
The present invention is directed to a method of treating the mental state of subjects with significant neurological, functional and/or motor impairment from an ischemic stroke. The method comprises a step of intravenously dosing ischemic tolerant allogeneic mesenchymal bone marrow cells itMSCs to subjects with ischemic stroke. In another aspect, the present invention is directed to treatment of the mental state with itMSCs of neurologic, functional, and/or motor deficits in patients with ischemic stroke.
Subject Patients.
Each of the cohorts neurologically assessed or examined for neurologic, functional, and motor deficits in patients contained seventeen or eighteen subjects with ischemic stroke.
A screening evaluation to determine if the subject was a suitable candidate for participation in this study was conducted prior to enrollment and treatment by the method of the invention.
The patients were evaluated upon admission according to the schedule of medical assessments to ensure eligibility of the subjects. Intravenous dosing of the itMSCs was performed on the morning of Day 1. Subjects remained in the hospital until stable and were regularly monitored for safety. Subjects that were clinically stable were discharged into the care of a responsible individual.
Follow-up visits for assessment of safety occurred daily for 3 days (days 2, 3, 4), again in one week (day 10) and at 1, 3, 6, 9, and 12 months post-treatment.
Adverse events, concomitant medications, vital signs, clinical laboratory test results, physical examinations, neurologic examinations, and neurologic assessment tools were collected or conducted at follow-up visits according to the schedule of assessments.
Study Endpoints
Primary
The primary endpoint of safety and tolerability of treatment with itMSCs during the twelve-month study period were determined by the incidence and severity of adverse events, clinically-significant changes on clinical laboratory tests, vital signs, physical and neurologic examinations.
Secondary
The change from baseline on neurologic and physical exam plus the following neurologic assessment tools were conducted at 1, 3, 6, 9, 12 months post-treatment, as available:
National Institutes of Health Stroke Scale (NIHSS)
Mini Mental Status Exam (MMSE)
Barthel Index (BI)
The Geriatric Depression Scale (GDS)
Subject Selection
Subjects were selected using the following inclusion and exclusion criteria.
Inclusion Criteria:
Exclusion Criteria:
Study Treatment
All subjects were dosed at a single dose level that was at or below the highest dose determined to be safe in the safety phase of this study.
Administration of itMSCs
On Day 1 an intravenous line was placed into an appropriate vein on the upper extremity with 0.9% sodium chloride running to keep the vein open. Within 1 hour prior to infusion, the appropriate number of itMSCs was diluted into 100 ml of 0.9% sodium chloride and infused intravenously within 50 minutes.
Prior to treatment a skin test to bovine serum was administered using 0.1 ml aliquot of the Stem Cell Media (Bovine Growth Serum Hyclone). If the patient had a reaction during the infusion, the infusion was interrupted or slowed according to the degree of reaction.
The patient remained remained in the hospital for observation for 24 hours. When clinically stable, the patient was discharged home with a responsible adult, and was monitored according to the schedule of assessments (Appendix B).
Concomitant Therapy and Clinical Practice
Patients continued all of their regular medications unless contraindicated. Rehabilitation (i.e., Physical, speech, and/or occupational therapy) were instituted upon returning home, as clinically indicated. Specific rehabilitation interventions and modalities were based upon the subject-specific evaluation findings, impairments, treatment plans, and goals.
Statistical Methods
The efficacy analyses included subjects that received the full dose of itMSCs and had the appropriate follow-up ratings completed per the schedule of assessments (i.e., Efficacy Evaluable Population). Efficacy of the neurological assessment tools: NIHSS, MMSE, BI, and MS were employed across the entire efficacy evaluable population.
The physical and symptomatic responses observed from this study of the actions of the MSCs on the central nervous system supported the present method of treating to obtain the benefits of itMSCs regenerative therapy in neurologic and neurodegenerative disease.
To assess the safety and tolerability of ischemic tolerant allogeneic mesenchymal bone marrow cells (itMSCs) administered intravenously to patients with ischemic stroke.
Secondary Objectives
To assess the clinical effects on the patient's mental state of treatment with itMSCs on neurologic, functional, and motor deficits in patients with ischemic stroke.
Mental State and Neurologic Exam
It should be understood that the term “mental state” as used herein means a patient's phenotype as reflected in the patient's performance on neurologic exams compared to baseline measurement on mental state assessment tools, such as but not restricted to National Institute of Health Stroke Scale (NIHSS), Mini Mental Status Examination (MMSE), The Barthel Index (BI), and Geriatric Depression Scale (GDS).
In clinical practice, mental state examinations are appraisals of the appearance, behavior, mental functioning and overall demeanor of a person. In some ways it reflects a “snapshot” of a person's psychological functioning or a person's capacity to function at a given point in time.
A typical mental state examination considers or appraises the following domains:
Appearance: A person's appearance can provide useful clues into their quality of self-care, lifestyle and daily living skills in terms of distinctive features, clothing, grooming, and hygiene.
Behavior: As well as noting what a person is actually doing during the examination, attention is paid to behaviors typically described as non-verbal communication. These can reveal much about a person's emotional state and attitude. Appraisal is made of the patient's facial expression, body language and gestures, posture, eye contact response to the assessment itself, rapport and social engagement, level of arousal (e.g. calm, agitated), anxious or aggressive behavior, psychomotor activity and movement (e.g. hyperactivity, hypoactivity), unusual features (e.g. tremors, or slowed, repetitive, or involuntary movements)
Mood and affect: Affect refers to immediate expressions of emotion, while mood refers to emotional experience over a more prolonged period of time. Affect is measured in term range (e.g. restricted, blunted, flat, expansive), appropriateness (e.g. appropriate, inappropriate, incongruous), stability (e.g. stable, labile). Mood could appear as happiness (eg, ecstatic, elevated, lowered, depressed), irritability (e.g. explosive, irritable, calm), stability.
Speech: Speech described behaviorally and described by its content is particularly revealing feature of a person's presentation. Unusual speech is sometimes associated with mood and anxiety problems, schizophrenia, and organic pathology. The following are typical measures: speech rate (e.g. rapid, pressured, reduced tempo), volume (e.g. loud, normal, soft), tonality (e.g. monotonous, tremulous), quantity (e.g. minimal, voluble), ease of conversation.
Cognition: This refers to a person's current capacity to process information and is important because it is often sensitive to mental health problems. The following are observed: level of consciousness (e.g. alert, drowsy, intoxicated, stuporose), orientation to reality (often expressed in regard to time/place/person—e.g. awareness of the time/day/date, where they are, ability to provide personal details), memory functioning (including immediate or short-term memory, and memory for recent and remote information or events), literacy and arithmetic skills, visuospatial processing (e.g. copying a diagram, drawing a bicycle), attention and concentration (e.g. observations about level of distractibility, or performance on a mentally effortful task—e.g. counting backwards by 7's from 100), general knowledge, language (e.g. naming objects, following instructions), ability to deal with abstract concepts (e.g. describing conceptual similarity between two things).
Thoughts: A person's thinking is generally evaluated according to their thought content or nature, and thought form or process. Content measures include: delusions (rigidly held false beliefs not consistent with the person's background), overvalued ideas (unreasonable belief, e.g. a person with anorexia believing they are overweight), preoccupations, depressive thoughts, self-harm, suicidal, aggressive or homicidal ideation, obsessions (preoccupying and repetitive thoughts about a feared or catastrophic outcome, often indicated by associated compulsive behavior), anxiety (generalized, i.e. heightened anxiety with no specific referent; or specific, e.g. phobias)
Process: Thought process refers to the formation and coherence of thoughts and is inferred very much through the person's speech and expression of ideas. Observed are: highly irrelevant comments (loose associations or derailment), frequent changes of topic (flight of ideas or tangential thinking), excessive vagueness (circumstantial thinking), nonsense words (or word salad), pressured or halted speech (thought racing or blocking)
Perception: Screening for perceptual disturbance is critical for detecting serious mental health problems like psychosis or severe anxiety, and mood disorders. It is also important in trauma or substance abuse. Perceptual disturbances are typically marked and may be disturbing or frightening. Disturbances include: Dissociative symptoms like derealization (feeling that the world or one's surroundings are not real), and depersonalization (feeling detached from oneself. Illusions include the person perceives things as different to usual, but accepts that they are not real, or that things are perceived differently by others. Hallucinations are probably the most widely known form of perceptual disturbance, hallucinations are indistinguishable by the sufferer from reality, could include command hallucinations (voices telling the person to do something) should be investigated, or associated to degrees of fear and/or distress associated with the hallucinations.
Insight & Judgement: Insight involves acknowledgement of a possible mental health problem, understanding of possible treatment options and ability to comply with these, and ability to identify potentially pathological events (e.g. hallucinations, suicidal impulses) Judgement refers to a person's problem-solving ability in a more general sense, and can be evaluated by exploring recent decision-making or by posing a practical dilemma (e.g. what should you do if you see smoke coming out of a house?)
The subjects of this study had significant functional and/or neurologic impairment from an ischemic stroke. The first part 1 was a dose escalation design. The second part determined efficacy of the present invention on a cohort based on the safety findings of Part 1.
Part 1 of the study consisted of three dose cohorts of subjects (n=5 per dose cohort) with ischemic stroke who were enrolled sequentially in an escalating dose manner, (see Appendix A), with subjects receiving the same weight based dosage of mesenchymal bone marrow cells:
It was determined to be safe to continue the study after the three cohorts were doses and observed.
For determining efficacy, the second part of the study enrolled an additional 18 subjects with ischemic stroke at for dosing at or below the highest safe dose level as determined from Part 1. Adverse events, concomitant medications, and assessments of neurologic status were recorded at each follow-up visit or contact from the patient and/or patient's caretaker, following discharge from the hospital daily on day 2, 3, 4 and 10 post-treatment, as shown in the above Schedule of Assessments. Complete neurological examinations and neurologic assessment tools were used to assess disability and functional status at baseline (prior to treatment), and at the visits scheduled at 1, 3, 6, 9, and 12 months post treatment. Computerized tomography (CT) was conducted at baseline only, unless CT or MRI were collected within 2 months of enrollment.
Upon completion of the cell transplantation, patients were encouraged to continue or begin participation in physical, occupational, and/or speech therapy (as appropriate based on the patient's diagnosis and baseline condition), which is thought to enhance and/or promote the effects of cell transplantation.
Efficacy Endpoint:
The change from baseline on neurologic and physical exam plus the following neurologic assessment tools conducted at 1, 3, 6, 9, 12 months post-treatment were available:
Study Enrollment
18 Subjects participated in this study for approximately 12 months as follows: up to 1 month for screening followed by treatment and follow-up.
Ischemic Tolerant Allogeneic Mesenchymal Bone Marrow Cells -itMSCs
Methods of preparing itMSCs for use in the present invention are disclosed in U.S. Pat. No. 8,790,081; Published U.S. Applications 2014/0286910; 2012/0201786, all of which are hereby incorporated by reference. In one aspect, the method of the invention employs itMSCs which are grown hypoxically in a defined serum medium, preferably a low serum medium of between about 0.2 and 2% serum.
Formulation, Packaging, And Preparation
On Day 1, the appropriate number of cryovials of allogeneic mesenchymal bone marrow cells per subject were thawed, washed and re-suspended in 10 ml of sterile 0.9% sodium chloride solution for injections according to the protocol. The final preparation for injection was made by diluting the allogeneic mesenchymal bone marrow cells into 100 ml 0.9% sodium chloride solution and used for intravenous dosing.
Dosage and Administration
Part 1 of this study was a dose escalation study evaluating three doses of stem cells, with subjects (n=5) receiving the same dose of allogeneic mesenchymal bone marrow cells based on weight per kilogram. Subjects were enrolled sequentially in a dose escalation manner, with subjects receiving one of three doses based on body weight and using the following cell aliquots: 25 million, 50 million, and 100 million allogeneic mesenchymal bone marrow cells, (Appendix A). No subjects received receive more than the maximum dosage of 150 million cells in this study.
In Part 2, the dosage of stem cells is determined from the safety data from Part 1 and did not exceed the highest safe dose as determined in Part 1.
Administration of itMSCs
The itMSCs were prepared as described above. On Day 1, an intravenous line was placed into an appropriate vein on the upper extremity or hand with 0.9% sodium chloride solution running to keep the vein open. Prior to treatment, a skin test to bovine serum was administered using 0.1 ml aliquot of the Stem Cell Media (Bovine Growth Serum Hyclone.
Within 1 hour prior to infusion, the appropriate number of allogeneic mesenchymal bone marrow cells was diluted into 100 ml of 0.9% sodium chloride solution that was infused intravenously within 50 minutes.
Product Storage and Stability
The Master Cell Bank (MCB) and the lot release of allogeneic mesenchymal bone marrow cells were be stored in liquid nitrogen. The tolerable duration of storage was determined by qualified personnel as part of stability program. Once the vials of a lot release were processed and the cell suspension was prepared for administration to a subject as described above, the dose of allogeneic mesenchymal bone marrow cells was stored at +4° C. until the time of administration. All cells were administered to the subject within 2-4 hours of preparation. Cells that were not used within this time period were discarded.
Concomitant Medications and Rehabilitation
Concomitant medications (any prescription and/or over-the-counter preparations) and therapies (nondrug or procedures) used by a subject while participating in this clinical trial were recorded from 28 days prior to Dayl, until the end of the study or the end of a subject's participation in the study.
Physical, occupational, and speech therapy were allowed and encouraged for all subjects pre- and post-treatment. Specific therapeutic interventions were determined by the subject's treating physician based upon the patient-specific evaluation findings, impairments, treatment plans, and goals.
Clinical Assessments:
Clinical Laboratory Assessments:
Imaging
Mental State Assessment Tools
Screening
All screening evaluations were completed within 30 days prior to treatment, unless otherwise indicated.
Assessments and Treatment
Day-1 (Outpatient Admission)
Follow-up Assessments
Days 2, 3 and 4
Day 10 (±1 day)
1 Month (Day 30±3 days)
Month 3 (Day 90±7 days)
Month 6 (Day 180±10 days)
Month 9 (Day 270±14 days)
Month 12 (Day 360±14 days)
Early Termination Visit
Efficacy Analyses
The actual score and calculated change from baseline for each outcome measure (NIHSS, MMSE, BI, GDS) were tabulated for each scheduled assessment visit. Summary statistics 1 consisted of sample size (N), means, standard deviations, medians, and minimum and maximum values were used to summarize the data. Subjects who received complete dose of itMSCs and had post-treatment assessments were used as the efficacy evaluable population for statistical analysis.
The primary efficacy endpoint was evaluated as a change from baseline to month 6 on the neurologic assessment tools. Subjects missing the month 6 score, but having a score from month 9 or 12 were included in the analysis and used those available data.
The following are summaries of the results of the method of the present invention for treating mental state which involves administration intravenously of itMSCs to patients suffering from neurologic, functional, and/or motor deficits after ischemic stroke by intravenously administering ischemic tolerant allogeneic mesenchymal bone marrow cells (itMSCs).
NHISS Results
MMSE Results
BI Results
GDS Results
Table 1 is a summary of the efficacy resulting from use of the method of the present invention.
The method of the present invention which involves a step of intravenously administering itMSCs to stroke patients achieved the following neurological benefits: in 10 of 17 patients, ameliorated depression as measured in changes in baseline of the Geriatric Depression Scale (Short Form); improved performance on the NIH Stroke Scale in 10 of 18 patients; improved performance on the MMSE in 13 of 17 patients; improved performance in 8 of 18 patients in the Barthel Index. In another aspect, the method of the invention finds application in treating the mental state of a post-ischemic stroke patient wherein the mental state comprises dementia.
This application claims the benefit of Provisional Patent application US62/197,424 filed Jul. 27, 2015.
| Number | Date | Country | |
|---|---|---|---|
| 62197424 | Jul 2015 | US |
