T-Regulatory Cells in Amyotrophic Lateral Sclerosis
|ALS (Amyotrophic Lateral Sclerosis)||Biological: Autologous T-regulatory lymphocytes Biological: Interleukin-2||Phase 1|
|Study Design:||Intervention Model: Single Group Assignment
Intervention Model Description:
Autologous infusion of expanded T-regulatory lymphocytes during early and late phases of ALS disease in patients with varying rates of disease progression.Masking: None (Open Label)
Primary Purpose: Treatment
|Official Title:||Expansion and Infusion of T-Regulatory Cells in Amyotrophic Lateral Sclerosis|
- Number of participants with treatment-related adverse events as assessed by CTCAE v4.0 [ Time Frame: Baseline to two years ]Clinical laboratory blood tests are standard to assure safety in clinical trials. Complete blood count, chemistry, liver function, throxine (T4) and thyroid stimulating hormone (TSH) will be assessed for normal reference ranges and abnormal (not clinically significant) results. Clinically abnormal results will be documented as adverse events as per CTCAE v4.0.
- AALS (Appel ALS) Scale [ Time Frame: Baseline to week 15 ]The AALS is a published, validated instrument that consists of five sub-scores: bulbar, respiratory, muscle strength, and lower extremity and upper extremity function. Each group is composed of individual tests. The total Appel ALS score is 30 for healthy subjects and 164 for those with maximum impairment. The rate of change in the Appel ALS Rating Scale is a significant predictor of survival for subjects with ALS.
- ALSFRS-R (ALS Functional Rating Scale-Revised) [ Time Frame: Baseline to week 15 ]The ALSFRS-r (ALS Functional Rating Scale-revised) is an orally administered validated instrument using an ordinal rating scale used to determine the subject's assessment of their capability and independence in 12 functional activities. The scale addresses fine motor, gross motor, bulbar and respiratory function. The ALSFRS-r is used as a clinical assessment in ALS standard of care and in most ALS clinical trials.
- T-Regulatory Cells [ Time Frame: Baseline to 3 months post treatment for a total of two years from baseline ]Treg percentage (CD4+CD25+FOXP3+ cells) within the total CD4+ population will be assessed by multicolor flow cytometry.
- Treg Suppression [ Time Frame: Baseline to 3 months post treatment for a total of two years from baseline ]Treg suppressive function of T-effector (Teff) cells will be assessed by [3H]-thymidine incorporation. Correlation between changes in the rate of disease progression and the Treg percentage and function will be determined by Spearman's correlation analysis.
- TH17 and Th1 lymphocytes [ Time Frame: Baseline to 3 months post-treatment for a total of two years from baseline ]The percentage of Tregs, Th1 lymphocytes and Th17 lymphocytes will be assessed by multicolor flow cytometry.
- Pulmonary FVC - Exploratory Measure [ Time Frame: Baseline to 3 months post-treatment for a total of two years from baseline ]FVC (Forced Vital Capacity). Reduction of pulmonary function is the primary source of morbidity and mortality in ALS. FVC testing will be used to monitor respiratory function. FVC measures the amount of air which can be forcibly exhaled from the lungs after taking the deepest breath possible.
- Pulmonary MIP - Exploratory Measure [ Time Frame: Baseline to 3 months post-treatment for a total of two years from baseline ]MIP (Maximum Inspiratory Pressure. Reduction of pulmonary function is the primary source of morbidity and mortality in ALS. MIP testing will be used to monitor respiratory function. MIP measures inspiratory muscle strength.
- Tracheostomy- Exploratory Measure [ Time Frame: Baseline to 3 months post-treatment for a total of two years from baseline ]Duration of tracheostomy-free survival
|Actual Study Start Date:||May 16, 2016|
|Estimated Study Completion Date:||March 2018|
|Estimated Primary Completion Date:||February 2018 (Final data collection date for primary outcome measure)|
Experimental: Treatment arm
All subjects are enrolled in the one arm consisting of infusions of autologous T-regulatory lymphocytes at a dose of 1x10 to the sixth/kg and subcutaneous injections of Interleukin-2 at a dose of 2x10 to the fifth IU/m2 three times a week.
Biological: Autologous T-regulatory lymphocytes
intravenous administration of Autologous T-regulatory lymphocytes at a dose of 1x10 to the sixth /kg.Biological: Interleukin-2
Subcutaneous Interleukin-2 at a dose of 2x10 to the fifth IU/m2, three times a week.
Other Name: IL-2
This Pilot Study will consist of 4 ALS subjects who will undergo 4 infusions of autologous expanded Tregs with concomitant subcutaneous injections of IL-2 (2 x 105 IU/m2) 3 times weekly for 52 weeks or at least until such time that interim analyses can confirm or negate its benefit.
During the enrollment period up to four subjects will be recruited from patients known to our clinic for screening, baseline measures and leukapheresis. The Treg cell manufacturing will be performed in a GMP laboratory. The first subject will receive infusions of their expanded Tregs (1x106 /kg) with concomitant subcutaneous IL-2 injections (2 x 105 IU/m2) 25 days (+/- 2 days) post leukapheresis. The 2nd subject will begin after the first subject has completed the first 4 weeks and has experienced no untoward effects during this period. Once subjects #1 and #2 have completed the first 4 weeks and no toxic events have occurred they will therefore be considered safely past the first milestone and subject #3 will begin infusions. After subject #3 has completed the first 4 weeks with no untoward effects, subject #4 may begin infusions with the below modified schedule:
The 4th subject will undergo infusion of autologous expanded Tregs once every four weeks (+/- 2 days) for a total of four infusions, with concomitant subcutaneous injections of IL-2 (2 x 105 IU/m2) 3 times weekly. In addition, subject #4 will begin subcutaneous IL-2 injections 4 weeks before his first autologous Treg infusion. An additional office visit will take place 2 weeks after initiating IL-2 for clinical evaluation, scoring and blood draw. Office visits will then be completed every two weeks while the subject is receiving Treg infusions for clinical evaluation, scoring, and blood draws. Then, the subject will be seen in office visits once per month for one year total for clinical evaluation, scoring, and blood draws.
In addition, subjects #1, 2 and 3 will repeat the leukapheresis (under a separate protocol) and undergo Treg infusions at the modified schedule of every 4 weeks, with concomitant subcutaneous injections of IL-2 (2 x 105 IU/m2) 3 times weekly. The subjects will be called on Day 7, and 21. Office visits will be completed on the day after infusions and every two weeks while the subjects are undergoing Treg infusions for clinical evaluation, scoring, and blood draws. The subjects will then be seen during office visits once per month for one year total from their initial baseline visit for clinical evaluation, scoring, and blood draws
Monthly interim analyses will monitor the subjects using validated ALS scales such as the ALSFRS-R and Appel Scale, which incorporates muscle strength and dysfunction, activities of daily living and pulmonary function. The analyses will also include interim medical history and physical exam, EKG when indicated, safety labs (such as CBC, chemistry, liver function, T4 and TSH) as well as more technical research labs such as T Regulatory Cell, Th1 and Th17 counts, FoxP3 RNA expression, and Treg Suppression Assays. A PT/PTT will be performed only if the subject has an abnormal coagulation result at baseline or if the subject is on anti-coagulation therapy.
Please refer to this study by its ClinicalTrials.gov identifier: NCT03241784
|United States, Texas|
|Methodist Neurological Institute|
|Houston, Texas, United States, 77030|
|Principal Investigator:||Stanley H Appel, MD||Houston Methodist Neurological Institute|