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Efficacy and Safety of Leriglitazone in Patients With Friedreich Ataxia: A Phase 2 Double-Blind, Randomized
Massimo Pandolfo1, Kathrin Reetz1, Alejandra Darling1
1Université Libre de Bruxelles (M. Pandolfo), Brussels, Belgium; Department of Neurology (K.R.), RWTH Aachen University, Germany; JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging (K.R.), Forschungszentrum Jülich GmbH, Germany; Hospital Sant Joan de Déu (A. Darling), Barcelona, Spain; La Paz University Hospital (F.J.R.R.), Madrid, Spain; Department of Radiology (P.-G.H., J.J., C.L., I.A., D.D.), Center for Magnetic Resonance Research, University of Minnesota, Minneapolis; Institut du Cerveau (ICM) (F.M.), Sorbonne Université, Paris, France; AP-HP (F.M.), Groupe Hospitalier Pitié-Salpêtrière, Département de Génétique, Paris, France; Department of Cardiology (F.P.), Sorbonne Université, AP-HP, Pitié-Salpêtrière University Hospital, Paris, France; Institute of Cardiometabolism and Nutrition (ICAN) (F.P.), Pitié-Salpêtrière Hospital, Paris, France; Allies in Cardiovascular Trials Initiatives and Organized Networks (ACTION) Group (F.P.), URC Lariboisière University Hospital, Paris, France; Minoryx Therapeutics SL (S.P., I.M.-U., A.V.-B., A.M., M. Pascual, M.M., U.M.), Barcelona, Spain; Minoryx Therapeutics BE (D.V.E.), Charleroi, Belgium; and Sorbonne Université (A. Durr), Paris Brain Institute, AP-HP, INSERM, CNRS, France.
Background And Objectives:
Friedreich ataxia (FRDA) is an autosomal recessive ataxia with no approved treatments. Leriglitazone is a selective peroxisome proliferator-activated receptor γ agonist that crosses the blood-brain barrier and, in preclinical models, improved mitochondrial function and energy production. We assessed effects of leriglitazone in patients with FRDA in a proof-of-concept study.
Methods:
In this double-blind, randomized controlled trial, eligible participants (age 12-60 years) had genetically confirmed FRDA, a Scale for the Assessment and Rating of Ataxia (SARA) total score <25, and a SARA item 1 score of 2-6, inclusive. Key exclusion criteria were age at FRDA onset ≥25 years and history of cardiac dysfunction. Participants were randomly assigned (2:1) to receive a daily, oral, individualized dose of leriglitazone or placebo for 48 weeks. The primary endpoint was the change from baseline to week 48 in spinal cord area (C2-C3) (measured by MRI). Secondary endpoints included the change from baseline to week 48 in iron accumulation in the dentate nucleus (quantitative susceptibility mapping) and total N-acetylaspartate to myo-inositol (tNAA/mIns) ratio.
Results:
Overall, 39 patients were enrolled (mean age 24 years; 43.6% women; mean time since symptom onset 10.5 years): 26 patients received leriglitazone (20 completed) and 13 received placebo (12 completed). There was no difference between groups in spinal cord area from baseline to week 48 (least-squares [LS] mean change [standard error (SE)]: leriglitazone, -0.39 [0.55] mm2; placebo, 0.08 [0.72] mm2; p = 0.61). Iron accumulation in the dentate nucleus was greater with placebo (LS mean change [SE]: leriglitazone, 0.10 [1.33] ppb; placebo, 4.86 [1.84] ppb; p = 0.05), and a numerical difference was seen in tNAA/mIns ratio (LS mean change [SE]: leriglitazone, 0.03 [0.02]; placebo, -0.02 [0.03]; p = 0.25). The most frequent adverse event was peripheral edema (leriglitazone 73.1%, placebo 0%).
Discussion:
The primary endpoint of change in spinal cord area was not met. Secondary endpoints provide evidence supporting proof of concept for leriglitazone mode of action and, with acceptable safety data, support larger studies in patients with FRDA.
Trial Registration Information:
ClinicalTrials.gov: NCT03917225; EudraCT: 2018-004405-64; submitted April 17, 2019; first patient enrolled April 2, 2019. clinicaltrials.gov/ct2/show/NCT03917225?term=NCT03917225&draw=2&rank=1.
Classification Of Evidence:
This study provides Class I evidence that individualized dosing of leriglitazone, compared with placebo, is not associated with changes in spinal cord area in patients with FRDA.
