Note: Descriptions are shown in the official language in which they were submitted.
~ W094117818 21 5 ~ ~ 4 0 PCT~S94/0~27
METHOD~ FOR TREATING ~IYO,K~PHIC LATE~AL
3ÇS.~8I~ WITH CNTF
BACKGROUND OF THE lN V~N'l'lON
The present invention includes methods for the
treatment of amyotrophic lateral sclerosis (ALS) in
human patients.
Amyotrophic lateral sclerosis (ALS) is a
progressive degenerative disorder of motor neurons in
the spinal cord, brainstem, and motor cortex,
manifested clinically by muscular weakness, atrophy,
and corticospinal tract signs in varying combinations.
ALS is a common disease, with an annual incidence
rate of 0.4 to l.76 per lOO,OOO population
(approximately î,OOO-4,300 in the U.S.). Most patients
are more than 50 years old at the onset of symptoms and
the incidence increases with each decade of life. ALS
occurs in a random pattern throughout the world; it is
estimated that in about 5% of cases ALS is familial,
being inherited as an autosomal dominant trait.
ALS affects neuromuscular functions in the hand,
leg, thoracic, abdominal, or posterior neck muscles.
Typical initial symptoms in the hand include
uselessness of hand, awkwardness in tasks requiring
fine finger movements, stiffness of the fingers, and
slight weakness or wasting of the hand muscles.
Cramping and fasciculations of the muscles of the
forearm, upper arm, and shoulder girdle muscles also
appears. With time, the other hand and arm may be
similarly affected. Eventually a patient exhibits
atrophic weakness of the hands and forearms, slight
spasticity of the legs, and generalized hyperreflexia.
Muscle strength and bulk diminish, abductors,
adductors, and extensors of fingers and thumb tend to
become weak before the long flexors, on which the
handgrip depends, and the dorsal interosseous spaces
become hollowed, giving rise to the "cadaveric" or
"skeleton hand". The patient may walk about with
WO94/17818 PCT~S94/01227
useless, dangling arms. Later the atrophic weakness
spreads to the neck, tongue, pharyngeal and laryngeal
muscles.
The principal finding is a loss of nerve cells in
the anterior horns of the spinal cord and motor nuclei
of the lower brainstem. There is an extensive neuronal
loss and gliosis involving the premotor area,
particularly the superior frontal gyri, and the
inferolateral cortex of the temporal lobes. Many of
the surviving nerve cells are small, shrunken, and
filled with lipofuscin. Lost cells are replaced by
fibrous astrocytes.
ALS has been observed in conjunction with
presenile and senile dementia, and with Parkinsons
disease. The course of ALS, irrespective of its
particular mode of onset and pattern of evolution, is
inexorably progressive. Half of the patients die
within 3 years and 90% within 6 years (Adams and Victor
(1989) in Principles of Neuroloqy 4th ed., McGraw-
Hill, Inc., New York.)
In ~;~eA~es which cause extensive damage to
striated muscle fibers, intracellular muscle fiber
enzymes leak out of the cell and enter the bloodstream.
One of the most commonly measured enzymes, and one of
the most sensitive measures of muscle damage, is
creatine phosphokinase (CPK). Serum CPK levels are
used to monitor muscle damage in certain neuromuscular
diseases, and as a marker for effective treatment. In
disease which cause denervation paralysis with muscular
atrophy, such as ALS, serum CPK levels may be elevated
up to 2-3 times normal. This phenomenon, occurring in
almost half of all patients with ALS, probably
represents ongoing muscle damage secondary to
progressive denervation.
A stAn~Ardized test has been developed to measure
the clinical deficit and progression of ALS. The test
battery, developed by the Neuromuscular Research Unit
WO94/17818 ~ 5 4 0 PCT~S94/01227
at the New England Medical Center is referred to as the
Tufts Quantitative Neuromuscular Exam or TQNE. See,
Andres et al. NeuroloqY 38: 409-413 (1988). The TQNE
is a validated test battery specifically designed to
measure the motor function and strength of ALS patients
as the disease progresses. The battery includes
testing of five major functional areas: bulbar,
respiratory, arm, leg, and fine motor activities.
The present invention includes the use of the
protein neurotrophic factor ciliary neurotrophic factor
(CNTF) to treat ALS. Neurotrophic factors are
naturally occurring proteins that promote the survival
and functional activities of nerve cells. Neurotrophic
factors have been found in the target cells to which an
innervating nerve cell connects. Such target-derived
neurotrophic factors regulate the number of contacts
formed between innervating nerve cells and the target
cell population, and are necessary for the survival and
maintenance of these nerve cells.
Neurotrophic factors are also found in cells that
are not innervated. An example of such a neurotrophic
factor is CNTF. Human CNTF and the gene encoding human
CNTF are described in detail in United States patent
numbers 4,997,929, 5,141,856 and co-pending United
States patent application serial number 07/857,544
filed March 24, 1992. Each of these documents are
specifically incorporated herein by this reference.
Although the biological role of CNTF has not been
conclusively established, CNTF appears to be released
upon injury to the nervous system and may limit the
extent of injury or neuronal damage.
Highly-purified CNTF has been shown to support the
survival in cell cultures of chick embryonic parasym-
pathetic, sympathetic, sensory, and motor neurons.
There is significant evidence to support the
proposition that CNTF is a neurotrophic factor for
peripheral primary neurons in vivo and in vitro. See,
WO94/17818 PCT~S94/01~7
~15~0
--4--
U.S. patent application serial number 07/735,538 filed
July 23, 1991, specifically incorporated herein by this
reference.
In the present invention, methods are provided for
the treatment of ALS by the administration of ciliary
neurotrophic factor (CNTF).
SUMMARY OF THE lNV~NllON
The present invention includes methods for the
treatment of ALS by administering a human protein
ciliary neurotrophic factor to a patient in need
thereof. In particular, the invention provides methods
for administering therapeutically effective amounts of
CNTF by therapeutically effective routes of
administration in order to treat patients suffering
from ALS.
In one preferred embodiment of the invention,
recombinant human CNTF is administered to human
patients suffering from ALS in doses of less than about
l0 ~g/kg/day. More specifically, daily doses of about
2-3 ~g/kg/day are utilized.
It is to be understood that both the foregoing
general description and the following detailed
description are exemplary and explanatory only and are
not restrictive of the invention as claimed.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
Reference will now be made in detail to the
presently preferred embodiments of the invention,
which, together with the following examples, serve to
explain the principles of the invention.
The present invention includes a method for r
treating a patient suffering from ALS by administering
to that patient the human neurotrophic factor CNTF.
In one embodiment of this invention, preferred
CNTFs are naturally occurring proteins. The naturally-
occurring proteins are preferred in part because they
WO94/17818 ~15 ~ 5 ~0 PCT~S94/01227
--5--
pose a possibly lower risk of producing unforeseen and
undesirable physiological side effects in patients
treated therewith. Human CNTFs are preferred for use
in this invention. However, to the extent that non-
human CNTFs are substantially equivalent to human CNTFsand possess equivalent biological activity, they are
considered to be within the scope of this invention.
For purposes of the specification and claims, a
protein is deemed to be "naturally-occurring" if it or
a substantially equivalent protein can be found to
exist normally in healthy humans. "Naturally-
occurring" proteins specifically includes forms of
proteins found to exist in healthy humans that are
partially truncated at the amino or carboxyl terminus
of such proteins or that have amino acids that are
deamidated or otherwise chemically modified.
"Naturally-occurring" proteins may be obtained by
recombinant DNA methods as well as by isolation from
cells which ordinarily produce them. "Naturally-
occurring" also encompasses proteins that contain orlack an NH2-terminal methionyl group as a consequence
of expression in E. coli.
"Substantially equivalent" as used throughout the
specification and claims is defined to mean possessing
a very high degree of amino acid residue homology (See
generally M. Dayhoff, Atlas of Protein Sequence and
Structure, vol. 5, p. 124 (1972), National Biochemical
Research Foundation, Washington, D.C., specifically
incorporated herein by reference) as well as possessing
comparable biological activity.
Substantially equivalent proteins of this
invention includes proteins that have a significant
degree of homology with the naturally occurring
protein, but have been modified to contain a limited
number of mutations or deletions within the amino acid
sequence. Only such modified proteins retaining the
biological activity of the naturally occurring proteins
WO94/17818 PCT~S94/01227
~5~ 3 ~
--6--
are included within the definition. Those skilled in
the art are competent to prepare mutated proteins based
on the known sequence of the naturally occurring
proteins according to well known procedures without
undue experimentation. The biological activity of such
mutations may also be determined (without undue
experimentation) according to the procedures described
herein by those skilled in the art.
"Biological activity" as used throughout the
specification and claims refers to the natural
neurotrophic activity of the CNTF proteins of this
invention. One measure of the biological activity of
CNTF accepted by those skilled in the art is the
ability to support the survival in cell cultures of
chick embryonic ciliary ganglia as described in U.S.
patent 5,011,914. A protein is considered to have the
same or comparable biological activity as the naturally
occurring proteins of this invention if the protein has
a specific activity within two orders of magnitude as
the naturally-occurring proteins of this invention.
Particularly preferred CNTFs of the present
invention are the naturally-occurring proteins that
have previously been described in a currently pending
United States patent application. This application is
U.S. Patent Application Serial No. 07/857,544 filed
March 24, 1992 of Collins et al., which is entitled
"Purified Ciliary Neurotrophic Factor." (See also,
U.S. patents 5,011,914; 5,141,856; and 4,997,929).
Other preferred forms of CNTF are described in U.S.
Patent Application Serial No. 07/753,176 filed August
30, 1992 of Collins et al., which is entitled
"Purification of Recombinant Ciliary Neurotrophic
Factor and C-Terminal Truncated Ciliary Neurotrophic
Factor". Each of these patents and patent applications
are specifically incorporated herein by reference.
The nucleic acid sequences of the genes encoding
human and animal CNTFs and the amino acid sequences of
WO94/17818 ~1 ~ 5 ~ 4 0 PCT~S94/0~27
such protein5 are given in U.S. patent numbers
4,997,929 and 5,14l,856. The present invention
encompasses non-glycosylated forms of CNTF as well as
truncated forms of the naturally-occurring and
recombinant CNTF proteins as described in the above
patents. In a further embodiment, CNTF is modified by
attachment of one or more polyethylene glycol (PEG) or
other repeating polymeric moieties. In the preferred
embodiment of this invention the CNTF used is
naturally-occurring recombinant human CNTF (rhCNTF).
Methods for producing the CNTFs of this invention
are also disclosed in the above-mentioned patents. One
disclosed method consists of isolating CNTF from
various sources, such as peripheral nerve tissues. A
second disclosed method involves isolating the genes
responsible for coding CNTF, cloning the gene in
suitable vectors and cell types, and expressing the
gene in order to produce the CNTF. The latter method,
which is exemplary of recombinant DNA methods in
general, is a preferred method of the present
inventiori. Recombinant DNA methods are preferred in
part because they are capable of achieving
comparatively higher amounts at greater purity.
Preferably, the above described CNTFs are produced
by the aforementioned method in "substantially pure"
form. By "substantially pure" it is meant that CNTF,
in an unmodified form, has comparable biological
activity to the purified CNTF described in United
States patent 4,997,929. It is to be recognized,
however, that derivatives of CNTF may have different
specific activities. In a preferred embodiment of the
present invention, a therapeutic composition comprising
CNTF is administered in an effective amount to patients
in order to effectively treat the symptoms of ALS.
Because it is possible that the function of the
preferred CNTFs is imparted by one or more discrete and
separable portions of the CNTF protein, it is also
W094/17818 PCT~S94/0~27
~ 4 ~ -8-
envisioned that the method of the present invention
could be practiced by a~;n;~tering a therapeutic
composition whose active ingredient consists of that
portion (or those portions) of CNTF which controls (or
control) CNTF function.
The therapeutic composition of the present
invention is preferably administered parenterally by
injection. In the most preferred embodiment the
parenteral administration is subcutaneous. Also, other
effective administration forms, such as parenteral
slow-release formulations, intrathecally by continuous
infusion from an implanted pump, inhalant mists, orally
active formulations, or suppositories, are also
envisioned. The CNTF of this invention is preferably
formulated with a pharmaceutically acceptable carrier.
A pharmaceutically acceptable carrier is a carrier that
is not harmful to the patient and does not degrade,
deactivate, or in any other way h; n~er the effects of
the CNTF. One preferred carrier is physiological
saline solution, but it is contemplated that other
pharmaceutically acceptable carriers may also be used.
In one preferred embodiment it is envisioned that the
carrier and the CNTF constitute a physiologically-
compatible, slow-release formulation. The primary
solvent in such a carrier may be either aqueous or non-
aqueous in nature. In addition, the carrier may
contain other pharmacologically-acceptable excipients
for modifying or maint~;ning the pH, osmolarity,
viscosity, clarity, color, sterility, stability, rate
of dissolution, or odor of the formulation. Similarly,
the carrier may contain still other pharmacologically-
acceptable excipients for modifying or maint~; n; ng the r
stability, rate of dissolution, release, or absorption
of the CNTF. Such excipients are those substances
usually and customarily employed to formulate dosages
for parenteral administration in either unit dose or
multi-dose form or for intrathecal delivery by
~ WO94/17818 ~15 5 ~ 4 0 PCT~S94/01227
continuous or periodic infusion from an implanted pump
or intrathecally by periodic injection.
Once the therapeutic composition has been
formulated, it may be stored in sterile vials as a
solution, suspension, gel, emulsion, solid, or
dehydrated or lyophilized powder. Such formulations
may be stored either in a ready to use form or
requiring reconstitution immediately prior to
administration. The preferred storage of such
formulations is at temperatures at least as low as 4C
and preferably at -70C. It is also preferred that
such formulations cont~i~;ng CNTF are stored and
administered at or near physiological pH. It is
presently believed that storage and administration in a
formulation at a pH below approximately p~ 5.5 and
above approximately pH 8.0 is undesirable.
Preferably, the manner of parenterally
administering the formulations cont~;ning CNTF is via a
subcutaneous or intramuscular route. The most
preferred a~ini~tration is parenterally via a
subcutaneous route. To achieve the desired dose of
CNTF, single or repeated subcutaneous or intramuscular
injections may be administered. It is believed that
the administration of CNTF in doses below approximately
0.005 ~g/kg/day may not be effective, while the
administration of doses of greater than 10mg/kg/day may
have undesirable side effects. In a preferred
embodiment of the invention the dose of CNTF is between
0.5-50 ~g/kg/day. To treat or prevent the progression
of ALS, it may be desirable to administer the CNTF
periodically. The periodic administrations may
constitute monthly, bi-weekly, weekly, daily or hourly
regimes. The required frequency of administration will
be apparent to those treating the patient based on
standard observational techniques.
In Example 2 below, patients suffering from ~LS
were administered daily injections of rhCNTF in dosages
WO94117818 ~ t ~ Q PCT~S94/01227
--10--
including 2 ~g/kg/day, 5 ~g/kg/day, lO ~g/kg/day and 20
~gkg/day. The progression of the ALS symptoms in the
patients were monitored by the TQNE evaluation.
Surprisingly, as seen in the results shown in Tables
III and IV, the most positive trends were seen in the
patient group which had been administered 2 ~g/kg/day.
Thus, in a preferred embodiment of the invention,
patients suffering from ALS are administered rhCNTF in
doses of less than about lO ~g/kg and preferable about
2-3 ~g/kg. Further, in the preferred embodiment the
rhCNTF is administered once daily.
It is also contemplated that certain formulations
cont~;n;ng CNTF are to be administered orally.
Preferably, CNTF which is administered in this fashion
is encapsulated. The encapsulated CNTF may be
formulated with or without those carriers customarily
used in the compounding of solid dosage forms.
Preferably, the capsule is designed so that the active
portion of the formulation is released at that point in
the gastro-intestinal tract when bioavailability is
maximized and pre-systemic degradation is minimized.
Additional excipients may be included to facilitate
absorption of CNTF. Diluents, flavorings, low melting
point waxes, vegetable oils, lubricants, suspending
agents, tablet disintegrating agents, and binders may
also be employed.
Regardless of the manner of administration, the
specific dose is calculated according to the
approximate body weight or surface area of the patient.
Further refinement of the calculations necessary to
determine the appropriate dosage for treatment
involving each of the above mentioned formulations is
routinely made by those of ordinary skill in the art
and is within the ambit of tasks routinely performed by
them without undue experimentation, especially in light
of the dosage information and assays disclosed herein.
These dosages may be ascertained through use of the
~ W094/17818 2 ~ ~ 5 5 4 0 PCT~S94/01227
--11--
established assays for determining dosages utilized in
conjunction with appropriate dose-response data.
According to the present invention, a patient in
need of a treatment for ALS is administered a
therapeutically effective amount of CNTF. As described
above, the dosage sufficient to deliver a
"therapeutically effective amount" of CNTF can be
determined by those of ordinary skill in the art
without undue experimentation. A "therapeutically
effective amount" may be defined as the amount of CNTF
sufficient to giVe rise to subjective or objective
improvements in the condition of the patient suffering
from ALS.
It should be noted that the CNTF formulations
described herein may be used for veterinary as well as
human applications and that the term "patient" should
not be construed in a limiting manner. In the case of
veterinary applications, the dosage ranges should be
the same as specified above.
It is understood that the application of teachings
of the present invention to a specific problem or
environment will be within the capabilities of one
having ordinary skill in the art in light of the
teachings contained herein. Examples of representative
uses of the present invention appear in the following
examples.
~MPLE l:
A number of human subjects with amyotrophic
lateral sclerosis (ALS) were given subcutaneous doses
of recombinant human CNTF (rhCNTF) as part of an open-
t label, asc~n~;ng study assessing the safety,
tolerability and pharmacokinetics of CNTF. During a
portion of this study, patients were given a single
subcutaneous administration of rhCNTF each day for 28
days. (The rhCNTF was prepared in an E. coli
expression system as described in U.S. patent numbers
WO94/17818 PCT~S94/01227
-12-
4,997,929 and 5,14l,856 and U.S. patent application
serial no. 07/753,176).
Inclusion criteria: Patients included in the test met
the following criteria:
1. Unequivocal diagnosis of uncomplicated ALS
2. The patient was male or female between the
ages of 21-85 years.
3. The patient, if female, was postmenopausal
for at least two years, surgically sterile,
or, if the patient was of childbearing
potential, she had been practicing a method
of birth control considered effective and
medically acceptable by the investigator for
a minimum of 2 months prior to the study and
at least 2 months after the study ended.
4. The patient was an outpatient at the time of
enrollment.
5. The patient was willing to be housed for 7
days in a medical unit, and was able to
comply with the study visit schedule.
6. The patient's laboratory values for white
blood cells (WBCs) and differential,
hemoglobin, hematocrit, platelets, serum
electrolytes, SGOT, SGPT, alkaline
phosphatase, BUN an creatinine, total
bilirubin, and urinalysis were within
clinically acceptable limits.
7. The general physical condition of the patient
was such that the investigator considered the
patient to be acceptable for this study and
would survive at least six months.
8. The patient was given an informed consent or
assent that has been approved by an
institutional review board.
Exclusion criteria: Patients were excluded from the
WO94/17818 2 1 5 S~ ~0 PCT~S94/01227
-13-
test if they met any of the following criteria:
1. The patient has uncontrolled (over the last
30 days), clinically significant
cardiovascular, pulmonary, endocrine, or
gastrointestinal disease. The patient has
clinically significant hematologic,
metabolic, hepatic, or renal disease.
2. The patient's FVC and/or FEV1 is < 40% of
predicted.
3. The patient has evidence for GMl antibodies,
paraproteinemia, familial ALS, or "pure"
motor syndromes (Spinal muscular atrophy,
etc.)
4. The patient is lactating or pregnant.
5. The patient has received another
investigational drug within the past 30 days.
6. The patient has any other major neurologic
disease in addition to ALS.
7. The patient has had a major surgical
operation or severe infection within one
month prior to the day of dosing.
8. The patient has a history of recent ethanol
or drug abuse, or noncompliance with
treatment on other experimental protocols.
9. The patient has limited mental capacity such
that he/she cannot provide written informed
consent, information regarding adverse
experiences or comply with evaluation
procedures.
Clinical Supplies
The rhCNTF was supplied in a sterile solution
ready for injection. This solution was comprised of a
Tris (lOmM) and sodium phosphate buffered solution
(lOmM) at pH 7.2, containing 205 mM sodium chloride,
10% v/v glycerol, 0.2% w/w polysorbate 80, and 0.1%
human serum albumin. The concentration of rhCNTF was
WO94/17818 PCT~S94/01227
2 ~ -14-
either l.0 mg~mL or 4 mg/mL. The rhCNTF and placebo
were packaged in 3 cc glass vials with Teflon-faced
butyl rubber stoppers. Each vial contained l.7 mL of
formulated material. This study also used a placebo
which was the vehicle for dilution of rhCNTF. The
rhCNTF and placebo were stored frozen at -20 or -70
degrees Celsius. Frozen, formulated rhCNTF and placebo
were thawed at room temperature. Prior to use, the
liquid formulations were gently inverted several times
to afford a homogenous solution.
Dosing of rhCNTF was performed with a l or 3 cc
syringe fitted with a 27 gauge needle. In order to
administer very low doses, for which the volume of l
mg/mL solution is too small to measure accurately, a
solution of O.l mg/mL was produced by adding 0.43 mL of
l mg/mL solution to one vial of placebo (l.7 mL).
Anecdotal Results
Groups of six patients each were daily injected
with 0.002, 0.005, O.Ol or 0.02 mg/kg of rhCNTF. 7
placebo patients at various dosage amounts were
included in the study. Anecdotal results of the
patients completing the 28 day regime are given below
in Table I.
In summary, 2 of the 7 placebo patients
experienced subjective improvement. Subjective
improvement or a decrease in hyperreflexia, cramps or
fasciculations on exam was reported by 15 of the 21 ALS
patients receiving rhCNTF who completed the trial.
CPK Results
Serum levels of creatine phosphokinase (CPK) were
measured in the test group of patients at various times
for most patients, levels of serum CPK were determined
prior to the initiation of a~r;ni~tration, on the day
the treatment began and weekly thereafter. The results
of these measurements are shown in Table II below. In
~ WO94/17818 21~ 5 ~ 4 0 PCT~S94/01227
-15-
Table II, under the column Drug/Placebo, D represents
patients who received CNTF and P represents patients
who received placebo, and the number represents the
dosage of CNTF in mg/kg/day.
In summary, in patients who received daily
injections of rhCNTF, serum CPK levels decreased in 5
of 6 patients, receiving 0.005 mg/kg/day of rhCNTF, 6
of 6 patients receiving 0.0~ mg/kg/day of rhCNTF and 3
of 3 patients receiving 0.02 mg/kg/day. Patients
receiving placebo showed no obvious correlations to a
decrease in serum CPK levels.
It is reasonable to conclude from this data that
the reduction in CPK correlates to a reduction in
muscle damage or breakdown. This result may be a
function of a primary protective effect on muscle cells
or from a secondary protective effect from improvement
in the function of innervating motor neurons. Either
explanation is possible in that CNTF receptors are
found on both neurons and on muscle cells.
Example 2
ALS patients meeting the inclusion and exclusion
criteria set forth in Example 1 were given a daily
single subcutaneous administration of rhCNTF. The
condition of the patients in the study was monitored by
TQNE.
The Neuromuscular Research Unit at the New England
Medical Center has developed a st~n~rzied test battery
to measure the clinical deficit in ALS, the Tufts
Quantitative Neuromuscular Exam (TQNE). See, Andres,
PL, et al. Neurology 1986; 36: 937-941 (Quantitative
motor assessment in amyotrophic lateral sclerosis); and
Andres, PL, et al. Neurology 1988; 38: 409-413 (Use of
composite scores (Megascores) to measure deficit in
ALS). The major component of the TQNE is the
measurement of maximum voluntary isometric contraction
(MVIC) of 10 muscle groups in the arms and lO muscle
wo 94,l78l8 ~ ~ 5 5 ~ ~ ~ PCT~S94/01227
-16-
groups in the legs using a strain guage tensiometer.
The TQNE is most commonly used to measure disease
progression and efficacy of investigational agents.
The TQNE measurements obtained at a given visit
are transformed to megascores as described in Andres
1988 reference sura, by averaging the Z-transformed
items (the raw score minus the mean, divided by the
st~n~rd deviation of the TUFTS ALS population for that
score) that compose that category.
Table 3 shows TQNE changes over 28 days of
treatment in patients receiving daily subcutaneous
injections of rhCNT~. The left column lists muscle
groups and their respective megascores. Each column
group to the right of this is a dose level (placebo, 2
5, lO, and 20 ~g/kg/day). Individual columns group in
each are patients who had evaluable TQNEs at baseline
and at Day 28. A "+" sign demonstrate a 28-day score
better than the baseline score. A "-" sign
demonstrates a 28-day score worse than the baseline
score. "@" signifies no changes. Table 4 shows a
summary table of megascore improvement per dose group.
Although changes in this small number of patients
are not statistically significant, there is a positive
trend in the 2 ~g/kg/day dose group.
WO 94/17818 215 5 5 4 0 PCT/US94/01227
TABLE I
DO8E L~ L PATIBNT ~ RY
0.002 mg\kg\day Pt. 2-0002; walking improved (more upright, longer distances) by 2nd week
of study, lnsted until 3 weeks after study.
Pt. 2-0004; d~_..aso~ frequency of falling; before study, OOD; during
study, 4 times over 28 days. One week after CNTF stop,oed, returned to 000.
Pt. 2-0006; improved movement of toes on left foot, still present one month
after stopping CNTF.
Placebo; ; .:_ ~ in speech and climbing stairs, as ~ell as ~ _rea3
fasciculations.
Pt. 3-0001; hyperreflexin diminished.
Pt. 3-0002; "perceived i o:.
0.005 Placebo; improved strength and longer ability to use walker.
Pt. 4-0101; fewer cramps
Pt. 4-0102; fewer fasciculations
Pt. 3-0104; strength improved, walked without cane.
Pt. 3-0105; cramps stop,oed after day 2, walking and speed improved
0.01 Pt. 2-0203; by secor,d week, reported improved ability to use a straw (pull
liquid into mouth), which persisted 2 weeks after end of study.
Pt. 2-0201; fewer cramps and fasciculations, more hand motility
Pt. 2-0203; fewer fasciculations
Pt. 2-0204; fewer fnsciculations
0.02 Pt. 5-0301, increased strength in arms and hands, started within several
days nfter starting CNTF. Also, not dropping things as much. Neuro exam
' ,~.
Pt. 3-0304; improved left foot/leg strength, hyperreflexia diminished, less
de~ on cane.
WO 94/17818 PCT/US94/01227
N ~ N O ~ X ~ X X ~ ~ N
N ~ N Ul , NUl
o
-- CO ~ ~ oO N3~ O
N N N _ ~ ~ -- r~ o O U~
H
-- O ~ _ 0 ~ O r-~
~Nj~ C$ ~~ N~ N~ ~ ~ N ~ N N N ` ~ 00
N ~ N _ N ~ ' '
r
Q _ N N N N O N N NIt~ O O trt In Ut U~ O
Il 1111111~ 111111 111111 11 1111 11 11 11 11 11
Q Q ~ Q C Q Q Q Q ~L ~ Q Q Q Q Q Q
OOOOOOOOOOOO------O
WO 94/17818 215 ~5 ~ ~ . PCT/US94/01227
o
;~; N ~ G C~
NlC , N ~ ~ E
~ _ ~ . ~ ;~ ~ u~ , 8
o
~ ~ 8 lC ;~ - $ ~ X Si;
~ N N NN _ N
et:
O æ - ~ N ~8
O` ' `
X
O O O O O o N N o
U ~1111 U11 11 11 11
Cl OI--~O ~ G 0 1--
No No No oN No No No oN o
WO 94/17818 PCT/US94/01227
~C~ i 5 ~ -20-
Z N ~ J
W ~,,, ...... ,,
3 ~
~ N . ~ . . . . ~ . .
~, - ~ .
H U~ a
H O ~ ~ ' ~ ' I I ' ' ' ' t
0 ~3 ~ W , ' ' ' , . , ~ t
W '~ a ~ , ~ .
Oî
. .
O' _ N ~ . ~ I , , , ~ , , , ~ I
~; N ~
U~
~n , t ' ' ' ~ . .
N ~ ~ ~ t I ~ . ~ ~ +
X ~ g ~ ~
WO 94/17818 21 S 5 5 4 ~ PCT/US94101227
--21--
o
-
o
O ~
o o o
o o o l ~ ~ ~
o o o
z
o
o
3 ~ o
o o
N I ~ I ' ' O O O U~
1 ~
.~ ' ~ ~n
C I I ~ E;
1 C
O ~ S
)'~ 0 0
~ S~
O
a ~ ~ ~, c g
J ~ _ K ~ _iY ~ 1~ C~
+ I ~
WO 94/17818 PCT/US94/01227
~1355 4~3
--22--
o~ o o o ~ o
U ~ X
~;
o
o o o o
~n _
W
Z ,c
a ~ ~ 0 u~
~ 0
~` 1 0
~ o ~C
A ~
:Z
0
Pl ~ N
0 0 0 ~
m
