T-regulatory Cells in ALS

NCT ID: NCT04055623

Last Updated: 2021-10-06

Basic Information

• Recruitment Status: UNKNOWN
• Clinical Phase: PHASE2
• Total Enrollment: 12 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2019-08-07
• Study Completion Date: 2022-08-31

Brief Summary

This study is a randomized, placebo-controlled, phase 2a trial to study the biological activity, safety, and tolerability of regulatory T Lymphocytes (Tregs) taken and expanded outside of the body and returned back to the same person whose Treg were removed, given back by IV (intravenously) and in combination with low-dose IL-2 in people with Amyotrophic Lateral Sclerosis (ALS).

Detailed Description

Based on data collected in a previous study with a small group of patients, evidence was found to show that interfering with the immune system using Treg cells slowed ALS disease progression. It is known that Treg cell numbers and function are reduced in patients with ALS and in some patients with lower Treg cells, they have a more marked rapid progression of their ALS. For this study, there are two sites (in Houston, Texas and Boston, Massachusetts) in which Tregs will be taken from participants, increased or expanded outside the body, and then re-administered back to the participants from which the Tregs came.

This study has two parts and due to the pandemic two groups [Group 1 and Group 2]:

1. The first period is a 6-month, randomized, placebo-controlled part of the study to study the biological activity, safety, and tolerability of the monthly expanded Tregs administered intravenously (IV) OR placebo (saline) administered intravenously plus subcutaneous low-dose Interleukin-2 (IL-2) OR subcutaneous placebo (saline) injections in 12 adults with ALS. IL2 helps regulate the immune system's white blood cells. [Group 1 only.]

2. The second period is a 6-month OPEN-LABEL part of the study (no placebo) in which all participants will receive their own expanded Treg cells administered intravenously in combination with subcutaneous low-dose IL-2 at the following schedule: single dose of Treg cells twice (once per month with three IL2 injections per week); followed by double the dose of Treg cells twice (once per month with three IL2 injections per week); followed by triple the dose of Treg cells twice (one per month with three IL2 injection per week); followed by a 1 month follow-up safety visit after the last triple dose of Tregs with was received and the last set of IL2 injections three times per week injections. [Group 1 and Group 2.]

Groups:

GROUP 1 will go through the double-blind part of the study (receive either Tregs infusions and IL2 injections OR saline infusions and saline injections) for six months and open label part of the study (receive Treg injections and IL2 injections) for six months.

GROUP 2 will receive only the open label (Tregs infusions and IL2 injections) for six months.

This study is studying whether the enhancement of Treg numbers and function will slow disease progression.

In the first study of Tregs, we completed a single-center, open-label phase I study of Tregs from people with ALS. Tregs were increased outside the body and returned back to the individual Treg owners in multiple doses every 2 to 4 weeks. This early study provided evidence in a small group of patients that treatment with autologous Tregs may be effective in slowing ALS progression.

Conditions

ALS (Amyotrophic Lateral Sclerosis)

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: TRIPLE

Study Groups

Intravenous infusion of Treg cells + Interleukin-2 injections

For the first six months: T-regulatory cells taken from a participant will be increased in numbers outside the body in a lab and then returned back to the same participant through intravenous (IV) infusions once per month. The participant will also take Interleukin-2 (IL2) injections three times per week.

Group Type: EXPERIMENTAL

Monthly autologous Treg cells infusions + 3 times per week Interleukin-2 injections

Intervention Type: BIOLOGICAL

For the first 6-months of the study: T-regulatory cells taken from a patient, increased in number in a lab, and returned through monthly intravenous (IV) infusions back to same patient + 3 times per week subcutaneous Interleukin-2 injections

Intravenous infusion w/Placebo + matching placebo injections

For the first six months: Participants will receive matching placebo or inactive intravenous (IV) infusions once per month. The participant will also take a matching inactive placebo injection three times per week.

Group Type: PLACEBO_COMPARATOR

Monthly placebo infusions + 3 times per week placebo injections

Intervention Type: OTHER

For first 6-months of study: monthly placebo infusions + 3 times per week subcutaneous placebo injections

2nd 6-months Open Label: Treg Infusions + IL-2 injections

For second six months: All participants will receive their own expanded/increased in numbers Treg cells by monthly infusion plus 3 times per week subcutaneous injections of IL-2.

Group Type: EXPERIMENTAL

Monthly autologous Treg cells infusions + 3 times per week Interleukin-2 injections

Intervention Type: BIOLOGICAL

For the second 6-months of the study: all participants will receive T-regulatory cells taken from the patient, that have been increased in number in a lab, and returned through monthly intravenous (IV) infusions back to same patient (Treg cell owner) + 3 times per week subcutaneous Interleukin-2 injections.

Interventions

Monthly autologous Treg cells infusions + 3 times per week Interleukin-2 injections

For the first 6-months of the study: T-regulatory cells taken from a patient, increased in number in a lab, and returned through monthly intravenous (IV) infusions back to same patient + 3 times per week subcutaneous Interleukin-2 injections

Intervention Type: BIOLOGICAL

Monthly placebo infusions + 3 times per week placebo injections

For first 6-months of study: monthly placebo infusions + 3 times per week subcutaneous placebo injections

Intervention Type: OTHER

Monthly autologous Treg cells infusions + 3 times per week Interleukin-2 injections

For the second 6-months of the study: all participants will receive T-regulatory cells taken from the patient, that have been increased in number in a lab, and returned through monthly intravenous (IV) infusions back to same patient (Treg cell owner) + 3 times per week subcutaneous Interleukin-2 injections.

Intervention Type: BIOLOGICAL

Other Intervention Names

Individualized therapy Treg cell infusions + Interleukin-2 (IL-2); Proleukin is brand name for IL-2; inactive drug; Individualized therapy Treg cell infusions + Interleukin-2 (IL-2); Proleukin is the brand name for IL-2

Eligibility Criteria

Inclusion Criteria

• ALS meeting El Escorial criteria for possible, probable, lab-supported probable, or definite ALS.
• At least 18 years old.
• Provided informed consent and authorized use of protected health information (PHI) in accordance with national and local patient privacy regulations.
• Capable of complying with all study procedures, including the study drug delivery procedure, in the Investigator's opinion.
• On a stable regimen of riluzole for at least 30 days at the time of screening. If not on riluzole at the time of study entry, willing to refrain from initiation of the agent for the duration of the trial.
• Patients on edaravone willing to refrain from taking edaravone on the same day as they will receive the Tregs infusion for the duration of the trial. If not on edaravone at the time of study entry, willing to refrain from initiation of the agent for the duration of the trial.
• Medical record documentation of a decline in ALSFRS-R total score of at least two points in the 90 days prior to screening or at least four points over the 180 days prior to screening.
• Forced vital capacity (FVC) ≥65% of predicted capacity for age, height, and gender at screening.
• Patient able and willing to undergo leukapheresis.

Exclusion Criteria

• Presence of any of the following clinical conditions that would interfere with the safe conduct of the study, as determined by the Investigator:

• Unstable neurological, cardiovascular, cerebrovascular, pulmonary, renal, hepatic, endocrine, or hematologic disease; active malignancy or infectious disease; or other medical illness.
• Unstable psychiatric illness defined as psychosis (hallucinations or delusions), unstable major depression or substance abuse within 180 days prior to screening.
• Persistent asthma, prior history of acute systemic reactions involving immunoglobulin E (IgE)-dependent mechanisms, history of angioedema, or history of anaphylactic reactions to any medication.
• Serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) greater than 3 times the upper limit of normal (ULN) at screening.
• Serum creatinine greater than 1.8 mg/dL or creatinine clearance less than 40 mL/min at screening.
• History of or positive test result for human immunodeficiency virus (HIV), hepatitis C virus, or hepatitis B virus (i.e., positive for both hepatitis B surface antigen and hepatitis B core antibody) at screening.
• Tracheostomy.
• If female, breastfeeding, known to be pregnant, planning to become pregnant during the study, or unwilling to use effective contraception for the duration of the trial and for 90 days after treatment.
• If male of reproductive capacity, unwilling to use effective contraception for the duration of the trial and for 90 days after treatment.
• Enrollment in any other interventional study.
• Treatment with another investigational drug, biological agent, or device within 30 days or 5 half-lives of screening, whichever is longer. Patient participation in an observational/non-interventional clinical study is to be discussed with the Medical Monitor.
• Prior gene or cell therapy treatments for ALS.

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Massachusetts General Hospital

OTHER

Sponsor Role: collaborator

The Center for Clinical and Translational Sciences (CCTS) Clinical Research Unit at The University of Texas Health Science Center at Houston

OTHER

Sponsor Role: collaborator

North East Amyotrophic Lateral Sclerosis Consortium

NETWORK

Sponsor Role: collaborator

The Methodist Hospital Research Institute

OTHER

Sponsor Role: lead

Responsible Party

Jason R. Thonhoff

Principal Investigator, Houston Methodist Neurological Institute

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Stanley H. Appel, MD

Role: STUDY_DIRECTOR

The Methodist Hospital Research Institute

Jason R. Thonhoff, MD, PhD

Role: PRINCIPAL_INVESTIGATOR

The Methodist Hospital Research Institute

James D. Berry, MD, MPH

Role: PRINCIPAL_INVESTIGATOR

Massachusetts General Hospital

Locations

Massachusetts General Hospital Neurological Clinical Research Institute

Boston, Massachusetts, United States

Houston Methodist Hospital

Houston, Texas, United States

Countries

United States

References

Sakaguchi S. Naturally arising Foxp3-expressing CD25+CD4+ regulatory T cells in immunological tolerance to self and non-self. Nat Immunol. 2005 Apr;6(4):345-52. doi: 10.1038/ni1178.

Reference Type: BACKGROUND

PMID: 15785760 (View on PubMed)

Viglietta V, Baecher-Allan C, Weiner HL, Hafler DA. Loss of functional suppression by CD4+CD25+ regulatory T cells in patients with multiple sclerosis. J Exp Med. 2004 Apr 5;199(7):971-9. doi: 10.1084/jem.20031579.

Reference Type: BACKGROUND

PMID: 15067033 (View on PubMed)

Dejaco C, Duftner C, Grubeck-Loebenstein B, Schirmer M. Imbalance of regulatory T cells in human autoimmune diseases. Immunology. 2006 Mar;117(3):289-300. doi: 10.1111/j.1365-2567.2005.02317.x.

Reference Type: BACKGROUND

PMID: 16476048 (View on PubMed)

Bluestone JA, Buckner JH, Fitch M, Gitelman SE, Gupta S, Hellerstein MK, Herold KC, Lares A, Lee MR, Li K, Liu W, Long SA, Masiello LM, Nguyen V, Putnam AL, Rieck M, Sayre PH, Tang Q. Type 1 diabetes immunotherapy using polyclonal regulatory T cells. Sci Transl Med. 2015 Nov 25;7(315):315ra189. doi: 10.1126/scitranslmed.aad4134.

Reference Type: BACKGROUND

PMID: 26606968 (View on PubMed)

Beers DR, Henkel JS, Zhao W, Wang J, Huang A, Wen S, Liao B, Appel SH. Endogenous regulatory T lymphocytes ameliorate amyotrophic lateral sclerosis in mice and correlate with disease progression in patients with amyotrophic lateral sclerosis. Brain. 2011 May;134(Pt 5):1293-314. doi: 10.1093/brain/awr074.

Reference Type: BACKGROUND

PMID: 21596768 (View on PubMed)

Zhao W, Beers DR, Liao B, Henkel JS, Appel SH. Regulatory T lymphocytes from ALS mice suppress microglia and effector T lymphocytes through different cytokine-mediated mechanisms. Neurobiol Dis. 2012 Dec;48(3):418-28. doi: 10.1016/j.nbd.2012.07.008. Epub 2012 Jul 17.

Reference Type: BACKGROUND

PMID: 22820142 (View on PubMed)

Henkel JS, Beers DR, Wen S, Rivera AL, Toennis KM, Appel JE, Zhao W, Moore DH, Powell SZ, Appel SH. Regulatory T-lymphocytes mediate amyotrophic lateral sclerosis progression and survival. EMBO Mol Med. 2013 Jan;5(1):64-79. doi: 10.1002/emmm.201201544. Epub 2012 Nov 9.

Reference Type: BACKGROUND

PMID: 23143995 (View on PubMed)

Beers DR, Zhao W, Wang J, Zhang X, Wen S, Neal D, Thonhoff JR, Alsuliman AS, Shpall EJ, Rezvani K, Appel SH. ALS patients' regulatory T lymphocytes are dysfunctional, and correlate with disease progression rate and severity. JCI Insight. 2017 Mar 9;2(5):e89530. doi: 10.1172/jci.insight.89530.

Reference Type: BACKGROUND

PMID: 28289705 (View on PubMed)

Alsuliman A, Appel SH, Beers DR, Basar R, Shaim H, Kaur I, Zulovich J, Yvon E, Muftuoglu M, Imahashi N, Kondo K, Liu E, Shpall EJ, Rezvani K. A robust, good manufacturing practice-compliant, clinical-scale procedure to generate regulatory T cells from patients with amyotrophic lateral sclerosis for adoptive cell therapy. Cytotherapy. 2016 Oct;18(10):1312-24. doi: 10.1016/j.jcyt.2016.06.012. Epub 2016 Aug 3.

Reference Type: BACKGROUND

PMID: 27497700 (View on PubMed)

Thonhoff JR, Beers DR, Zhao W, Pleitez M, Simpson EP, Berry JD, Cudkowicz ME, Appel SH. Expanded autologous regulatory T-lymphocyte infusions in ALS: A phase I, first-in-human study. Neurol Neuroimmunol Neuroinflamm. 2018 May 18;5(4):e465. doi: 10.1212/NXI.0000000000000465. eCollection 2018 Jul.

Reference Type: RESULT

PMID: 29845093 (View on PubMed)

Thonhoff JR, Berry JD, Macklin EA, Beers DR, Mendoza PA, Zhao W, Thome AD, Triolo F, Moon JJ, Paganoni S, Cudkowicz M, Appel SH. Combined Regulatory T-Lymphocyte and IL-2 Treatment Is Safe, Tolerable, and Biologically Active for 1 Year in Persons With Amyotrophic Lateral Sclerosis. Neurol Neuroimmunol Neuroinflamm. 2022 Aug 29;9(6):e200019. doi: 10.1212/NXI.0000000000200019. Print 2022 Nov.

Reference Type: DERIVED

PMID: 36038262 (View on PubMed)

Other Identifiers

Pro00022167

Identifier Type: -

Identifier Source: org_study_id