Sunday, 23 March 2014

Politics: lessons from the simvastatin trial

What can we learn from the positive Simvastatin trial? #MSBlog #MSResearch

"At last it has been published; the MS-STAT study. Jeremy Chataway presented the results at the ECTRIMS meeting in Lyon, in October 2012. We have had a lot of discussion about these results on this blog in the past. The good news is that this phase 2 study shows that high dose simvastatin reduces the rate of brain atrophy in SPMSers and delays disease progression. Is this a eureka moment? No. Three issues need to be addressed. (1) How does simvastatin work? (2) Is there a dose effect? (3) Where to from here?"

"(1) How does simvastatin work? Why do I ask this? There have been several other trials of statins in MS that have been negative or equivocal. Some of these studies have used doses that are of similar potency to the dose used here, i.e. 80mg. Therefore is simvastatin working via MS-specific mechanisms, MS non-specific mechanisms but as a neuroprotective agent, or is it targeting the so called comorbidities such as vascular disease that may speed up MS disease progression. It is important to identify the mechanisms before this strategy is taken forward."

" (2) Is there a dose effect? 80mg per day is a very large dose and is more likely to be associated with side effects, in particular adverse effects on muscle function (weak muscles called a myopathy). It is important to know if lower doses are effective. This will allow dose titration to minimise side effects. In addition, the EMA and FDA tend to require a dose titration as part of any of development programme when they consider drugs for licensing."



"(3) Where to from here? Who is going to take simvastatin forward? With the current level of risk associated with drug development and the amount of regulatory red-tape it seems unlikely that an alternative, or competitor, to the current pharmaceutical industry model will emerge. The current big pharma model does not facilitate repurposing of existing drugs, i.e. the development of drugs that have been discarded or that have too short a patent life to encourage investment. Big Pharma may be tempted to innovate in areas where patent protection is achievable, but obviously show no interest in developing off-patent drugs for new indications. Simvastatin for progressive MS is just such an example. The questions at this point are: (i) Who is going to fund a phase III clinical development programme of simvastatin in progressive MS, for a drug that costs £2.06 per month (80 mg, 28-tab pack, British National Formulary)? The development costs will be many millions of pounds, even for investigator-led studies. Pharma did not even support the phase II study, so the likelihood of substantial pharma investment, for a drug out-of-patent is slim. (ii) Will regulatory approval be required for risk averse neurologists to prescribe simvastatin? Even if neurologists decide to prescribe simvastatin would NHS England and insurance companies pay for an unlicensed drug? (iii) Will regulatory approval of simvastatin require one or two phase III studies, as is currently required of Pharma? (iv) Even if a phase 3 programme was funded, who will take responsibility for licensing, and maintaining the license, for simvastatin for people with SPMS? (iv) Who will monitor safety aspects once approved? Without a licence would the health providers also be at risk of legal action should side-effects become manifest or if licenced products became available. As simvastatin is off-patent there is no incentive for an investor to undertake such studies. Will government funding agencies or medical charities step in to do this?"

"In 2012, The Wellcome Trust and the Department of Health launched a drug repurposing initiative as part of a “Health Innovation Challenge Fund”. Whilst this initiative is commendable, the funds available were simply not large enough to complete phase III clinical trials in slowly progressive neurological disorders and importantly – there is no allowance for subsequent funding to take the drug through the regulatory process to obtain and maintain a license. Furthermore there was no clear path other than getting pharma support, past clinical trials which is some way off delivering medicines to patients . In reality, the repurposing initiative is to fund proof-of-concept studies, presumably to find new targets using existing drugs that can then be exploited by Big Pharma with pro-drugs or new chemical or biological entities. However, without changing the regulatory framework there may be no incentive for this to happen. If it is not feasible to develop licensed drugs to the stage that they can actually be prescribed for a new indication, we surely cannot justify – neither ethically nor economically – the undertaking of such proof-of-concept studies. They become little more than an academic exercise, creating false hopes for people in desperate need of treatments. Although the National Institute of Clinical Excellence (NICE) should surely have no quarms about supporting the cost-effectiveness of cheap generic drugs, their role would become superfluous if non-expensive drugs became the norm. In contrast the Medical and Healthcare products Regulatory Agency (MHRA) has no interest in the cost of drugs. They concern themselves with safety and so are unlikely to support cost- cutting or creating any unfair advantage over their pharma paymasters."

"An alternative to the system Big Pharma currently uses is required that enable the repurposing of existing drugs to the point that doctors can actually prescribe such drugs to their patients. Firstly, regulators and politicians need to acknowledge that we have a problem. The time for reflection may be right; in this age of austerity when drug budgets are soaring, repurposing of existing drugs could and should help contain costs. The cost of the current Pharma model are simply too high to be sustainable in the long-term, certainly as long as society remains committed to the NHS’ core principles, including that healthcare “be free at the point of delivery”.

"Putting the issue of privatisation and private prescriptions of drugs to one side, one proposal could be a new tax or levy on the sale of pharmaceuticals to pay for the costs of non-profit drug development. However, this is unlikely to work if the navigation of the regulatory red-tape remains so complex and expensive. In addition, the skills needed to apply for, and maintain a license generally reside in industry. Hypothecated or ring-fenced taxation as a way of paying for initiatives may not work as spending of such revenues tends to inefficient and the electorate may not support it." 


"A market-driven solution would be preferable. However, to achieve this regulators and politicians need to lower the bar for the repurposing of drugs. Only then can repurposing be done by non-profit organisations and/or academic institutions, and partners from the pharmaceutical industry could be incentivised to contribute to this process. Governments could create such incentives in a similar way they did for orphan drug development. In the US and EU it is easier to gain marketing approval for an orphan drug. There are other financial incentives, such as an extended exclusivity period, to encourage the development of drugs which might otherwise lack a sufficient profit motive. In the UK the collective buying power of the NHS, could be used to ring-fence the supply compounds to the NHS. Another possibility is to allow adaptive phase III programmes; i.e. long-term efficacy and safety data could be collected from post-marketing studies, once a drug has been given a provisional marketing authorisation. For example, the European Medicines Agency (EMA) and US Food and Drug Administration (FDA) had concerns about the long-term safety of oral cladribine in people with MS and hence requested additional data. Rather than producing such data, Merck-Serono, the manufacturer of oral cladribine, withdrew oral cladribine from markets in Russia and Australia where it had been licensed. This decision is particularly disappointing given their subsequently completed phase III trial of oral cladribine in clinically isolated syndrome suggestive of demyelination (CIS) study. In that study lasting two years the 3.5mg/kg dose of cladribine reduced the risk of conversion to clinically definite MS by 67% when compared to placebo and there were no new safety signals. Had cladribine been given a provisional license the drug could have been used on condition that every MSer taking the drug was registered in a pharmacovigilance study to assess long-term risks of the drug. The control group for this study could have been subjects treated with the licensed first line therapies (interferon-beta, glatiramer acetate and, more recently, teriflunomide and dimethyl-fumarate). The lack of flexibility to grant a conditional license by key regulatory authorities, threw the baby out with the bathwater and as a result people with MS have been denied a potentially highly effective – and safe – drug. Academia could take up the baton to repurpose the off-patent, generic, subcutaneous formulation of cladribine as a highly-effective and low cost (£1000/per lifetime) induction treatment for MS. However, without more flexibility of the licensing procedures any attempt to that effect will be in vain. Thus, in effect ensuring that the NHS pays high and recurrent drug costs and perpetuates rationing of access to expensive drugs."


"We therefore feel a new movement should be formed to support a “Big Pharma Alternative” ( BPA). The BPA should lobby politicians to change direction and create an alternative to the current Big Pharma model to develop drugs for MS and other diseases. The working model could be a non-profit, or social entrepreneurship, with the aim of getting legislation enacted similar to that for orphan-diseases. The primary objective is to create the environment that will allow academic institutions and non-profit organisations to develop drugs. The aim is to get drugs that are off-patent, or do not have sufficient patent life for Big Pharma to recoup development costs and make a profit, to the market under a provisional marketing authorisation, whilst the long-term safety data is being collected for a definitive marketing authorisation. As an alternative, the central buying power of the NHS, and closed market of the United Kingdom, makes it an ideal place for innovation to help deliver effective treatments to UK citizens in a cost-efficient manner, from which others can benefit. The BPA can work hand-in hand with pharma for many of these developments. With the introduction of legislation to support granting time-restricted exclusivity for supply and effectively extending the patent life and possible allowing some price adjustment, this could incentivise pharma to undertake the studies This is a political problem that requires a political solution, and it is a problem we literally cannot afford to ignore."



Chataway et al. Effect of high-dose simvastatin on brain atrophy and disability in secondary progressive multiple sclerosis (MS-STAT): a randomised, placebo-controlled, phase 2 trial. The Lancet, 19 March 2014. doi:10.1016/S0140-6736(13)62242-4.

Background: Secondary progressive multiple sclerosis, for which no satisfactory treatment presently exists, accounts for most of the disability in MSers. Simvastatin, which is widely used for treatment of vascular disease, with its excellent safety profile, has immunomodulatory and neuroprotective properties that could make it an appealing candidate drug for patients with secondary progressive MS.

Methods: We undertook a double-blind, controlled trial between Jan 28, 2008, and Nov 4, 2011, at three neuroscience centres in the UK. Patients aged 18—65 years with secondary progressive MS were randomly assigned (1:1), by a centralised web-based service with a block size of eight, to receive either 80 mg of simvastatin or placebo. MSers, treating physicians, and outcome assessors were masked to treatment allocation. The primary outcome was the annualised rate of whole-brain atrophy measured from serial volumetric MRI. Analyses were by intention to treat and per protocol. This trial is registered with ClinicalTrials.gov, number NCT00647348.

Findings: 140 participants were randomly assigned to receive either simvastatin (n=70) or placebo (n=70). The mean annualised atrophy rate was significantly lower in MSers in the simvastatin group (0·288% per year [SD 0·521]) than in those in the placebo group (0·584% per year [0·498]). The adjusted difference in atrophy rate between groups was −0·254% per year (95% CI −0·422 to −0·087; p=0·003); a 43% reduction in annualised rate. Simvastatin was well tolerated, with no differences between the placebo and simvastatin groups in proportions of participants who had serious adverse events (14 [20%] vs nine [13%]).

Interpretation: High-dose simvastatin reduced the annualised rate of whole-brain atrophy compared with placebo, and was well tolerated and safe. These results support the advancement of this treatment to phase 3 testing.

CoI: multiple, Jeremy Chataway is a member of MS@UCLP

28 comments:

  1. Prof. G will you be prescribing simvastatin to people with progressive MS?

    ReplyDelete
    Replies
    1. Re: "Prof. G will you be prescribing simvastatin to people with progressive MS?"

      Only if they have high cholesterol or a high risk of vascular disease. 80mg is a high dose and comes with a risk of side effects. At present we need these results confirmed and we need more safety data. You also need to remember that this study could be a false positive, this is why we do 2 or 3 trials to confirm our findings.

      On a positive note this study is an important milestone for SPMSers and what we need now is a way forward to test simvastatin in a phase 3 trial.

      Delete
  2. How can we help with the BPA? How about a national petition?

    ReplyDelete
    Replies
    1. Re: "How can we help with the BPA? How about a national petition?"

      Good idea; we have discussed this internally but feel we need more support and a wider lobby before launching this. I think we need over a 100,000 signatories to trigger a house of commons debate. This issue is not specific to MS and involves all other disease areas as well. Hence we need people from other specialities to help.

      Delete
  3. http://www.theguardian.com/society/2014/mar/19/multiple-sclerosis-treatment-research-statin

    ReplyDelete
    Replies
    1. Re: Guardian article

      May be I should have blown my own trumpet yesterday. The Daclizumab extension study was published on-line in the Lancet Neurology yesterday. I didn't inform our press office hence no press release.

      http://www.sciencedirect.com/science/article/pii/S1474442214700390

      Delete
  4. Prof G
    Would you agree that a drug which reduces brain WOLUME loss, measured by MRI, may not necessarily reduce brain TISSUE loss? Could it only reflect changes in processes associated with water accumulation/loss?

    ReplyDelete
    Replies
    1. Re: "Would you agree that a drug which reduces brain VOLUME loss, measured by MRI, may not necessarily reduce brain TISSUE loss? Could it only reflect changes in processes associated with water accumulation/loss?"

      Yes, of course. But the positive effect on EDSS or disability suggests this is a real phenomenon. Brain volume is complex, therefore it needs to be correlated with other markers of neuroprotection, for example reduced black hole evolution, improved MTR (tissue integrity marker), NMR spectroscopy (axonal marker), etc.

      This issue need a separate post.

      Delete
    2. I agree; these studies don't need press releases as they are both old news. The only time they deserve to be highlighted in the lay press is when and if they get a license to treat MS. Otherwise the press release simply creates unnecessary hype and disappoint. My neurologist has already turned down my request for simvastatin.

      Delete
    3. RE: "But the positive effect on EDSS or disability suggests this is a real phenomenon. "
      The difference reported between the mean EDSS scores at month 24 between the two treatment groups is not an accepted measure for disability accumulation. In particular when only 87% of the placebo patients had both a baseline and month 24 score.
      Awaiting your post.

      Delete
    4. This comment has been removed by a blog administrator.

      Delete
  5. Interesting re the vascular connection, but why the hype with this one ? I thought researchers were onto this a long while ago.
    http://informahealthcare.com/doi/abs/10.1517/14728222.7.5.613

    ReplyDelete
    Replies
    1. Re: "Interesting re the vascular connection"

      This refers to vascular disease; in particular small vessel disease or minor strokes. These are more common in MSers with high blood pressure, diabetes, smokers and those with high cholesterol. This is small vessel arterial disease and has nothing to do with veins or the venous side of the system.

      Delete
    2. Re: "...but why the hype with this one ? I thought researchers were onto this a long while ago."

      This is how long it takes translate ideas; the statin story broke in MS more than 10 years ago. Hype? I am not sure we are hyping the issue.

      Delete
  6. Like other DMTs will there be responders and non-responders to simvastatin?

    ReplyDelete
    Replies
    1. Re: "Like other DMTs will there be responders and non-responders to simvastatin?"

      I am not sure, but you won't really notice a difference on simvastatin. An effective neuroprotective drug for progressive MS is unlikely to improve function; it is likely to slow down the rate of disease progression. For example, instead of it taking 18 months to move from one walking stick (EDSS 6.0) to needing bilateral support (EDSS 6.5) it may take 36 or 48 months. Will you notice this? As an individual you won't therefore we have to rely in the trials to show you that the drugs work.

      Delete
  7. Re (1) How does simvastatin work?
    Why does it matter? Nobody seems to know how Copaxone works and we aren't even sure how the beta-interferons work.

    Re Even if neurologists decide to prescribe simvastatin would NHS England and insurance companies pay for an unlicensed drug?
    If it's so cheap, would it matter if the NHS/insurance companies don't pay? MS charities can help patients who can't afford to pay the £2.06 a month. Many patients will be happy to pay out of their own pockets.

    ReplyDelete
    Replies
    1. There is now an international push for progression the most important question is how do you get agents to people after you get evidence of efficacy. has this been discussed enough

      Delete
    2. We should also watch to see what success the Wellcome Trust millions bring in terms of drugs to. People The repurposing scheme has come to a close. Having written to the section leaders a couple of weeks ago it was not clear that they had avision outside pharma. Maybe it is time to forward this link to your MP and get an answer about where yoi tax pounds are going because it is not a good use of resource in the trials can never be converted to patient beefit. This ossie is bigger than MS and if the charites got together to lobby government then it would be easy to get this debated and it would be easy to get a hundred thousand signatires

      Delete
  8. There's a lot in here to consider. I can't speak for my NHS employers, so this is a personal view. First, have a look at the European Medicines Agency's webpage on Adaptive Licensing. It's a pilot under which they work with you to streamline the work needed for a licence by telling you in advance what they can accept and allowing adaptation of work midstream. Second, the BNF price is not the price that NHS hospitals pay - it's the price in the community (more or less). The hospital price of simvastatin 80mg is about half that. On the question of whether the NHS will allow the use of unlicensed medicines, it always has and always will. About a third of the medicines used in paediatrics are unlicensed or used outside their licence (which is the case here - simvastatin is licensed, but not for this use). Finally (for now) NIHR (http://www.nets.nihr.ac.uk/faqs/eligibility) has a route to funds for non-profit research. They work closely with NICE to fill in research gaps.

    I would argue that full phase III may not be needed. What you need is sufficient evidence to make the prescribing of a statin in a defined group of patients into a medically respectable option. The licence provides some legal protection but so does the Bolam principle where no licence exists (which is - broadly - that what you're doing is what a respectable body of your peers would do). So if MS specialists collectively agree the evidence is strong enough to justify a practice, they then need to satisfy NHS commissioners who - given the relatively low cost - may well agree to support it.

    ReplyDelete
    Replies
    1. What happens when a licensed product exists and how many trials are needed can you have one system for pharma and another for academics?

      Delete
    2. The adaptive licensing has just been announced by the EMA and is an approach for companies

      This appears to start with the early authorization of a medicine in a restricted patient population, followed by iterative phases of evidence gathering and adaptations of the marketing authorization to expand access to the medicine to broader patient populations.

      Delete
    3. I wonder how much this help from the EMA costs? or is this part of their £30,000 fee?

      Delete
    4. "So if MS specialists agree"......Have you tried to herd cats? :-)

      Actually there is UK Clinical Trial Network and they do indeed work together

      Delete
  9. There are some who propose that statins work because they are vitamin d analogues or allow the body to recycle vitamin d, not because of there effect on cholesterol. Any thoughts?

    ReplyDelete
    Replies
    1. There are other mechanisms independent of cholesterol, implecated such as isoprenoid precursors which affect the Rho pathways there are others

      Delete
    2. http://star.psy.ohio-state.edu/coglab/Miracle.html
      This mechanism seems plausible:-)

      Delete
  10. My husband takes 80mg of Simvastatin to reduce his cholesterol level and doesn't appear to have any adverse effects.
    My son has PPMS and so far no treatment other than physiotherapy.
    How can he get on a trial for Simvastatin?

    ReplyDelete

Please note that all comments are moderated and any personal or marketing-related submissions will not be shown.