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Flexibility of Adaptive Early Phase Study Designs

Sabina Paglialunga, PhD   Director, Scientific Affairs

Adaptive clinical trials are characterized by innovative and flexible designs that incorporate safety and other information acquired during a study to instruct the next steps in a trial. Typically, these pre-planned adjustments include sample size refinement, subsequent dose level selection, or allocation ratio. In the case of patient studies, adaptive elements may consist of inclusion/exclusion criteria adjustment or stopping rules based on success or lack of efficacy [1].  Adaptive study designs are well established for cancer trials [2], and while they are applied to a lesser degree in other indications, a limited search in ClinTrials.gov revealed nearly 95 non-oncology industry sponsored adaptive trials over the past decade. 

Regulatory Perspective on Adaptive Designs

As interest in flexible design elements grows across all indications, both the FDA and EMA have issued updated guidance on adaptive trial designs for drugs and biologics in recent years [3, 4]. For early phase exploratory studies, the FDA touts the advantages of an adaptive design that advises dosing, pharmacokinetic (PK) and pharmacodynamic (PD) responses, which may improve the design and possibly the chances of success of later-phase trials [3]. 

Adaptive Early Clinical Trial Designs

For single ascending dose (SAD) and multiple ascending dose (MAD) studies, adaptive design elements can be incorporated into the study protocol to add flexibility. This can be a valuable approach when there are still many unknowns in the initial clinical drug development phases. Case examples of recent adaptive protocols are highlighted in Table 1. These elements, such as alterations to drug dose, number of cohorts, or schedules of PK sampling and PD assessments, must be pre-specified in the protocol. For each adaptable component, limits should be set to address any safety concerns and to operate within acceptable risk parameters [5]. For example, if a blood sample schedule can be adjusted to optimize evaluable PK or PD data, the maximum number of blood draws should be noted in the protocol and not exceeded. 

Table 1. Case Studies of Early Clinical Trial Adaptive Study Designs

Case StudyStudy DesignAdaptive ElementsImplementation
Adaptive Dose and PK2-part SAD and MAD study in healthy volunteersDrug dose, infusion volume and/or rate, PK schedule (time points and number of samples)Adaptive elements were modified based on AEs, clinical finding, safety and tolerability resultsProtocol allowed for reduced PK sample number if data permitted 
Adaptive Cohort NumberSAD study in healthy volunteersCohort number and dose levels defined for groups 1-5 Option to add up to 2 additional cohorts Upon review of cohort 1-5 safety and PK data, the decision will be taken to continue with increased dose levels, or an intermediate dose, or to cancel cohorts 6-7  
Adaptive PD ResponseMAD study in participants with obesityNumber of PD assessments Multiple PD assessments evaluated in cohort 1 with option to omit or adjust PD schedule in subsequent cohorts Protocol also indicated the maximum number of PD assessments that can be taken
Adaptive Sample SizeFixed-dose combination vs free dose cross-over bioequivalence (BE) study in healthy volunteersSample size re-estimation Clinical study activity paused during COVID-19 pandemic before all participants completed cross-over scheme  Adaptive and interim analysis was performed to re-evaluate  study sample size and power, using a validated method for crossover BE design [6]. Trial results demonstrated BE based on completed participant data [7]

Advantages of Adaptive Early Clinical Trials

With pre-defined adaptive protocol elements, no amendments are required, which can save time and result in scheduling efficiencies. In the case of future pandemic outbreaks or other extraordinary situations, adaptive designs can serve as a mitigation step and potentially ‘save’ a study from timely delays or the need to repeat the trial. This approach was applied in a BE study, where sample size was re-assessed midway through trial conduct using validated statistical methods to complete the trial without further interruption from a COVID-19 outbreak [7]. Ultimately, the advantage of adaptive, early clinical trial designs can lead to both time and costs savings. Celerion’s Protocol Design and Development Scientists are trial experts and can design early clinical trials with flexible and adaptive elements to get the most out of a study, for less.

References

1. Pallmann P et al. BMC Med. 2018;16(1):29.   

2. Bothwell LE et al. BMJ Open. 2018;8(2):e018320.

3. Food and Drug Administration. Adaptive Designs for Clinical Trials of Drugs and Biologics  Guidance for Industry. 2019. https://www.fda.gov/media/78495/download.   

4. European Medicines Agency. Adaptive Pathways. https://www.ema.europa.eu/en/human-regulatory/research-development/adaptive-pathways    

5. Lorch U et al. BMC Med Res Methodol. 2014;14:84.   

6. Potvin D et al. Pharm Stat. 2008;7(4):245-62.   

7. Csonka D et al. Pharmacol Res Perspect. 2021;9(5):e00846.

Celerion continues its Celebration of Translating Science into Medicine for over a decade by highlighting how Celerion ScienceSM has contributed to the development of new therapeutics using our core competencies. While Celerion’s inventive spirit began over 50 years ago, our most important contribution to human health is happening right now, against COVID-19.

2020 has been a breakthrough year working with our biopharma clients to rapidly accelerate both vaccine development and therapeutic treatments against COVID-19.  The safety of our patients and employees is an integral aspect of bringing all of us Closer to a Cure and Celerion is proud to have created one of the most comprehensive bioanalytical offerings in the industry for COVID-19 testing, with reliable and rapid results for SARS-CoV-2 PCR testing  and antibodies against the virus.

Celerion remains at the forefront of innovative and novel technology to accelerate drug development, deliver high quality data and ensure participant safety. Over the past decade, Celerion has introduced several innovative, High-Tech systems.

Our Top 10 Innovative Technologies Implemented over the Past Decade:

2020 → Celerion delivers the Future of Pharmacy with state-of-the-art pharmacy suites for extemporaneous API compounding. The suites provide dedicated positive and negative pressure rooms for hazardous and non-hazardous material. In addition, the Lincoln pharmacy houses a devoted ADME suite and all Celerion pharmacies are USP <795>, <797>, and <800> compliant.

2020 → The latest enhancement to drug development is high-resolution mass spectrometry (HRMS). HRMS determines the exact mass of molecular ions and is applied in drug development to support in vitro metabolite identification as well as human ADME profiling studies. Our HRMS system is available at our Zurich bioanalytical laboratory.

2018 FibroScan® is a noninvasive ultrasound-like device that simultaneously measures liver fat and fibrosis. FibroScan® is an integral part of inclusion and exclusion criteria for early phase nonalcoholic steatohepatitis (NASH) studies. Available at our Lincoln, NE and Phoenix, AZ clinics, we have a large database of FibroScan pre-screened participants.

2018 → Celerion provides a fully automated early clinical trial data management platform through the integration of Celerion’s proprietary electronic data acquisition system, ClinQuick®, with OmniComm’s TrialMaster® electronic data capture solution.  This integration automates Celerion’s data acquisition system and provides consistent data management and reporting capabilities in one centralized database. It facilitates consistency of data collection across clinical sites, ensuring accurate and high-quality information.

2017 → Celerion uses biometric fingerprint technology to complement Verified Clinical Trials participant database registry. The registry enhances the quality and safety of clinical trials. Biometric fingerprint augments the accuracy and speed of verification as well as adding another layer of protection to ensure dual enrollment in a clinical trial does not occur.

2016Celexus® is Celerion’s client data information portal. Clients can access real-time clinical data with operational key performance indicators, a centralized repository for study documentation. The system also features a dynamic interactive experience for analyzing and interpreting clinical data.

2015Flow cytometry is a unique bioanalytical service offering. This technique is used to detect and quantify characteristics of a cell population or particles. Flow cytometry can measure T cell and NK cell panels as well as specific cell population isolations (CD cell molecules). Our system even determines simultaneous measurement of multiple cytokine, chemokine, immunoglobulin, or cell signaling targets from a single sample. Immune cell monitoring can be further investigated with ELISpot (enzyme-linked immunosorbent spot). ELISpot is useful to measure B-cell antigen-specific antibodies and T-cell secretion of IFN-γ. This bioanalytical service offering was introduced in 2017.

2014 → Lung clearance index is a sensitive measure of airway ventilation, able to evaluate early signals of efficacy for cystic fibrosis drug development. The system is available at Celerion’s Respiratory Center of Excellence in Belfast, UK, which also houses a dedicated on-site bronchoscopy suite allows bronchoalveolar lavage (BAL), whole-body plethysmography system as well as spirometry apparatuses.

2011 → Celerion’s highly automated ECG core lab uses an ECG acquisition Holter device to collect continuous digital 12-leads ECG recordings for cardiodynamic and safety ECGs.  LCD screens optimize data quality by allowing visual inspection of all 12 leads before each collection time point. Digital recordings enable prompt onsite or remote review of safety ECGs to address potential adverse events or subject safety concerns.  Using Bluetooth technology, this system was updated in 2015 for direct data capture.

2010 → Workload can be streamlined at the Speed of Science with Labnotes, an electronic bioanalytical laboratory notebook system that comprehensively captures study procedures, observations and results. The system ensures only reagents, solutions, equipment, and prepared standards within quality requirements are used (e.g. expiry, calibration, and preventative maintenance). Data can be reviewed immediately, reducing the chance of errors. Labnotes enables us to meet regulatory requirements for GxP, 21 CFR Part 11, and the FDA’s Electronic Records and Signature Rule.

 by Sabina Paglialunga, PhD  –  Director, Scientific Affairs, Celerion

COVID-19 is a highly infectious respiratory disease caused by the SARS-CoV-2 virus that has affected every corner of the world and nearly all aspects of daily life.  In a subset of COVID-19 patients, an exaggerated immune response can lead to acute respiratory distress syndrome (ARDS) requiring mechanical ventilation and leading to death. For society to return to “normal”, it is estimated that ~70% of herd immunity is required [1], which could result in thousands of casualties. Furthermore, this herd immunity target may not be achievable because it is still unknown if those with mild or asymptomatic cases of COVID-19 may not have built up sufficient immunity to prevent reinfection. Therefore, we must consider vaccination as the only viable option to eliminate this virus and thus the race is on to develop an effective vaccine against SARS-CoV-2.

Under the Microscope:

SARS-CoV-2 is a single stranded RNA virus, it is encapsulated by proteins and lipids. The virus has four main structural proteins; a spike glycoprotein (S), a small envelope glycoprotein (E), a membrane glycoprotein (M) and a nucleocapsid protein (N) in addition to other accessory proteins. A homotrimer of S-proteins facilitates binding to angiotensin-converting enzyme 2 (ACE2) receptor on host cells and cell entry [2]. The S-protein is therefore a key site for antibody neutralization, but vaccines developed against other viral protein are also under investigation.

Vaccines 101:

Vaccines boost immunity against infectious diseases through controlled exposure of an antigen, which can be an attenuated virus or fragments of viral proteins.  The immune system responds by generating antibodies that protect against future infection. Subsequent exposure to the virus or another infected individual then triggers antibody recognition and the virus is cleared via the immune system activation.  Adjuvants are applied to vaccine formulation to upregulate the antigenic response, and depending on the duration of protection, an additional booster shot may be needed.

Vaccine Safety Assessments:

Early clinical phase studies focus on safety, tolerability and immunogenicity, and throughout vaccine development particular attention is paid to hypersensitivity. While vaccines are generally considered safe, serious anaphylactic adverse events associated with immunization can occur, albeit they are extremely rare.  Hypersensitivity to the antigen, adjuvants and preservatives have been observed [3] and may require dose adjustment or re-formulation. Another aspect to consider during vaccine development is the potential to induce a Th2 response. Th2 is one of two T-cell responses stimulated when antigens are presented to T cells. The type of T cell response (Th1 vs Th2) results in a particular set of cytokines released. Vaccines depend on a Th1 response to generate immunoglobulins, which elicit immunity against viruses, bacterial and fungal infections. A Th-2 response can counteract Th1 by upregulating interleukin-10 which has anti-inflammatory function [4]. If a Th2-type response is established upon immunization, it can prevent Th1-type response as these are antagonistic processes and a Th2-bias can potentially exacerbate the infection [5].

Bioanalytical Support of Vaccine Trials:

Advanced bioanalytical assays are needed for efficacy and safety measures. It is important that these bioanalytical tests are robust and analytically validated for their context of use in order to support a clinical trial [6].  A variety of assays are available for vaccine drug development, which induce antibody titer, qPCR, ELISpot, cell profiling and cytokine biomarkers.

Table 1. Bioanalytical Assays for Vaccine Development

Bioanalytical Assays Utility Technology
Antibody titers Determine the amount of antibodies produced in response to inoculation Ligand binding methods such as ELISA or MSD
Neutralizing activity of the antibody Determine the extend in which antibodies can clear the virus Cell-based assays
Viral load Determine the presences and amount of virus qPCR
DNA vaccines Quantify exogenous viral DNA components qPCR
mRNA vaccines Quantify exogenous viral mRNA components qPCR
T-cell profiling Examine immune cell populations Flow cytometry
T-cell response Examine IFN-γ activation ELISpot
Antibody producing cells Evaluate ex-vivo stimulation of PBMC for antibody production ELISpot
Inflammatory cytokines Monitor the ‘cytokine storm’ and potential risk stratify for disease severity Ligand binding methods such as ELISA or MSD
Neutralizing antibodies (NAbs) assay Antibodies that develop against the biotherapeutic product that can impact it efficacy or safety profile Cell-based assays
Antibody Dependent Enhancement (ADE) Characterize the causes of acute lung injury that may occur following coronavirus vaccination Flow cytometry

Innovative Vaccine Platforms:

There are several platforms for vaccine development.  Each technique holds unique advantages and challenges when it comes to safety, manufacturing and scalability [7-9]. The following explores these considerations for the various vaccines under development during the current pandemic.

Table 2. Benefits and Considerations for COVID-19 Vaccine Platforms

Vaccine Type Benefits Considerations
Whole inactivated virus • Conserves viral structure
• Rapid development
• Potential for hyper-sensitivity and Th2-bias
• Culturing live virus
Live-attenuated recombinant virus • Site-directed attenuation • Potential to revert to virulent strain
• Not suitable for sensitive populations
Viral vector vaccines • Robust immune response • Cell-based manufacturing
• Anti-vector immunity
Subunit vaccines • Good safety profile • Adjuvant requirement
• Manufacturing costs vary
Virus-like particles • Conserves viral structure
• Multimeric antigen display
• Complicated assembly
mRNA vaccines • Increase the safety profile; non-integrating
• Egg and cell free
• Rapid, inexpensive and scalable manufacturing
• May suffer from instability
• Low immunogenicity
DNA vaccines • Non-infectious
• Egg and cell free
• Greater stability
• Potential for multiple antigens
• Rapid production
• Specialized delivery system required
• Potential for integration into human genome
• Low immunogenicity

Adapted from: Zhang et al. 2019 [8] & Prompetchara et al. 2020 [9].

A Coordinated Effort:

The urgency of developing, validating and disseminating a COVID-19 vaccine is palpable. Nearly 100* sponsors have shifted resources and pivoted to the COVID-19 indication. Regulatory agencies are even cutting red-tape to expedite clinical trials. The MHRA approved a COVID-19 vaccine trial in 7 working days. In addition, regulatory authorities have also been swift to implement a series of guidance documents to support sponsors and CROs. Recently, the FDA issued guidance on development and licensure of vaccines to prevent COVID-19. In Europe, similar guidelines have been released by EMA and MHRA. Moreover, countries worldwide are ramping up production of syringes, vials and related paraphernalia needed to inoculate millions once a vaccines is approved. This level of swift global coordination has not been seen before.

Ending the Pandemic:

To end the COVID-19 health crisis quickly, we’ll need more than one solution.  Biotech and pharma sectors as well as regulatory agencies and CRO stakeholders are up to the challenge as the race for a vaccine is well underway. Promising early results from vaccine developers such as the University of Oxford with a viral vector vaccine, and Moderna with an mRNA vaccine, are hopeful signs that relief is on its way.  With a number of different types of vaccines under investigation, this increases our chances of developing several safe and effective COVID-19 vaccines.

References:

1. Randolph HE, Barreiro LB. Herd Immunity: Understanding COVID-19. Immunity. 2020;52(5):737-41.

2. Walls AC, Park YJ, Tortorici MA, Wall A, McGuire AT, Veesler D. Structure, Function, and Antigenicity of the SARS-CoV-2 Spike Glycoprotein. Cell. 2020;181(2):281-92 e6.

3. McNeil MM, DeStefano F. Vaccine-associated hypersensitivity. J Allergy Clin Immunol. 2018;141(2):463-72.

4. Berger A. Th1 and Th2 responses: what are they? BMJ. 2000;321(7258):424.

5. Rosenthal KS, Zimmerman DH. Vaccines: all things considered. Clin Vaccine Immunol. 2006;13(8):821-9.

6. Kar S, Islam R. Rapid and robust bioanalytical assays are critical for SARS-CoV-2 therapeutic and vaccine development and beyond. Bioanalysis. 2020.

7. Thanh Le T, Andreadakis Z, Kumar A, Gomez Roman R, Tollefsen S, Saville M et al. The COVID-19 vaccine development landscape. Nat Rev Drug Discov. 2020;19(5):305-6.

8. Zhang C, Maruggi G, Shan H, Li J. Advances in mRNA Vaccines for Infectious Diseases. Front Immunol. 2019;10:594.

9. Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic. Asian Pac J Allergy Immunol. 2020;38(1):1-9.

*GlobalData search on 01-June-2020. GlobalData, John Carpenter House, UK.

Acknowledgments: Thank you to Celerion scientists Aernout van Haarst, Sumit Kar, Michelle Combs and Lorraine Rusch for editorial assistance.

Biosimilars are not an exact copy but are similar to the originally approved biological product. Following an abbreviated pathway, they demonstrate equivalent PK, toxicity, similarity, and no clinical change compared to the innovator. The goal of a biosimilar is to introduce lower cost alternatives that can help improve patient access to biological treatments.

Celerion is the premier CRO for PK/PD assessments in healthy subjects and small patient groups. Building upon our bioequivalence and bioavailability expertise, we can design appropriate comparative studies to establish biosimilarity with marketed reference drugs that rely on pharmacodynamic biomarkers and potentially avoid larger patient studies.

With a legacy of over 50 years in clinical research, this year marks a decade of translating science to medicine as Celerion.  To commemorate our 10-year anniversary, we are highlighting 10 years of Biosimilars experience.


Our Top 10 lists of Biosimilars Turn-Key Programs and Bioanalytical Assays:

    1. Adalimumab: Monoclonal antibody that targets and inhibits tumor necrosis factor α (TNFα) activity. Adalimumab is indicated for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, psoriasis, hidradenitis suppurativa, uveitis, and juvenile idiopathic arthritis. Marketed as Humira, the US patent expired in 2016.
    2. Bevacrizumab: Monoclonal antibody that inhibits vascular endothelial growth factor A (VEGF-A). Bevacrizumab is indicated for colon cancer, lung cancer, glioblastoma, and renal-cell carcinoma and age-related macular degeneration.  Marketed as Avastin, the patents expired in the US in 2019 and in Europe in January 2022.
    3. Teriparatide:  A recombinant 34 amino acid portion of human parathyroid hormone (PTH), indicated for osteoporosis. Originating product, Forteo/Forsteo patent expired in 2019.
    4. (Peg)Filgrastrim: Neupogen is the originator filgrastrim product recombinant granulocyte colony-stimulating factor (G-CSF) indicated for conditions of neutropenia. Neulasta is a pegylated form of filgrastrim. Pegylation increases the half-life and stability. Neupogen patent expired in 2006 in Europe and 2013 is the US. Neulasta patent expired in 2015 and 2017 in the US and EU respectively.
    5. Ustekinumab: Marketed as Stelara, it targets IL-12 and IL-23 and is indicated for plaque psoriasis, Chron’s disease and ulcerative colitis. Patents expires in 2023 in the US and in 2024 in Europe.
    6. Omalizumab: Sold under the brand name Xolair, omalizumab is indicated for asthma and chronic idopathic utricaria. By inhibiting immunoglobulin E from binding to high affinity receptors on mast cells and basophils, omalizumab reduces sensitivity to allergens.  Patent expired in 2017 in the US and Europe.
    7. Ranibizumab: Ranibizumab is a monoclonal antibody fragment that inhibits angiogenesis by inhibiting VEGF-A. It treats age-related macular degeneration, a common source of vision loss with aging. It is also effective in diabetic macular edema. The brand name is known as Lucentis and its patent expires in June 2020 in the US and 2022 in Europe.
    8. Cetuximab: A monoclonal antibody that inhibits epidermal growth factor receptor (EGFR) used for the treatment of metastatic colorectal cancer, metastatic non-small cell lung cancer and head and neck cancer. The patent for the brand name product, Erbitux, expired in 2014 in Europe and in 2016 in the US.
    9. Trastuzumab: Monoclonal antibody, sold under the brand name Herceptin. Trastuzumab is a HER2 receptor antagonist, indicated for breast and stomach cancers that are HER2 receptor positive. Patents expired in 2014 in the EU and 2019 in the US.
    10. Etanercept: Commonly known as Enbrel, it is a TNFα inhibitor that functions as decoy receptor for the cytokine. Etanercept is indicated for various rheumatic and psoriatic disorders. US patent is extended to 2028, however the patent is expired in EU and biosimilars are available in this region.

See our full list of biosimilar experience https://live-celerion.pantheonsite.io/wp-content/uploads/2019/07/Celerion_Biosimilars_120617.pdf

The global COVID-19 pandemic has altered the mechanics of nearly every industry. For early phase clinical trials, adapting to this crisis has led to augmented risk mitigation procedures and greater use of innovative technology. Since continuity of your drug program is important to you, the patients in need of these therapies, it is important to us.

We have taken a proactive approach to conducting business, now when research is needed more than ever. Our strengths lie in being flexible and nimble, which is a benefit during times of uncertainty.

Our ‘New Normal’ is built on three key pillars; Safety, Resources and Communication.


Safety First

The health and safety of our participant and staff is of the utmost importance. We have incorporated several measures to screen, clean and isolate for COVID-19 virus during trial operations. We are following all CDC, FDA and MHRA guidelines as well as local regulations   for clinical operations during the COVID-19 pandemic.

Testing, Testing, Testing! Celerion Bioanalytical Services has focused capabilities on COVID-19 screening by PCR, viral load quantification, antigen detection, antibody titer measurement, cell-mediated immunity assessments as well as cytokine and chemokine inflammation biomarker assays.

 


We Lead Quality

 

We have the essential resources in place to safely and effectively execute your clinical trial.


Communication is Key

With conditions rapidly changing, effective communication among all stakeholders is critical.

During this dynamic situation, the steps we have put in place for the safety of participants and staff, securing supply chain and innovative technology are designed with one objective in mind, to help our biotech and pharma partners get their products to market faster.

Contact the Author

by Sabina Paglialunga, PhD – Director, Scientific Affairs, Celerion

SARS-CoV-2 symptoms include fever, cough and shortness of breath. The disease is especially hard on vulnerable populations such as the elderly and those with underlying health conditions like obesity and hypertension. Now, developing reports indicate that children may also be at great risk than originally thought.  


Into the Eye of the Storm

The virus primarily enters the body via the respiratory tract, and into lung cells through ACE2 receptors.  To counteract, the body mounts an immune response to defend against the foreign virus.  However, this attack tends to occur several days after initial infection, by when significant amount of viral shedding has already occurred, contributing to the wide spread of the disease.  As part of the defense process, there is an influx of immune cells, which include macrophages and T cells to the respiratory tract, leading to an overall systemic upregulation of pro-inflammatory cytokines (e.g. IL-6, IL-1β, TNFα) as well as interferon (IFN) signaling and production anti-viral factors. The resulting immune response drives B cells to create antibodies against SARS-CoV-2. These antibodies recognize the virus, neutralize and clear it from the body.  

While many infected individuals are asymptomatic or present with mild symptoms. Since the ACE2 receptors are also expressed in gastrointestinal tissues, abdominal symptoms are associated with COVID-19.  More severe cases will result in pneumonia, sepsis, acute respiratory distress syndrome (ARDS) requiring hospitalization and even death. Researchers have found that a hyper-immune response is associated with the most severe COVID-19 cases. Early studies from China reported patients in intensive care units (ICU) had dramatically elevated levels of IL-6, IL-10 and TNFα, accompanied by a reduction in CD4+ and CD8+ T cells [1]. This hyper-, pro-inflammatory state is often referred to as the cytokine storm or cytokine release syndrome (CRS). In this state, pro-inflammatory cytokines are released in excess amounts, creating an exaggerated cytokine response.  This can lead to not only damage to the virus and infected host cell but also healthy cells too. In the lungs, destruction of areole cells can result in hypoxia and ARDS, which may lead to death.  Similar finding of increased levels in IL-2, IL-7, G-CSF, CXCL10, MCP-1, MIP-1α, and CXCL10, CCL7 were subsequently reported, suggesting the hyper-inflammation associated with severe COVID-19 exacerbates lung damage [2, 3]. The cytokine storm is thought to be driven by IL-6 [4]. In that respect, the virus also infects monocytes, macrophages and dendritic cells that can result in their activation and further secretion of IL-6. 


Navigating the Current Pandemic with Past Coronavirus Experience 

The raging cytokine storm also contributed to morbidity in patients infected with other Coronaviruses. There are seven known human coronaviruses.  The 229E, HKU1, NL63, OC43 strains are associated with the common cold, however more virulent forms  have resulted in major past outbreaks; SARS (Severe Acute Respiratory Syndrome) in 2002 and MERS (Middle Eastern Respiratory Syndrome) in 2012. SARS, MERS and COVID-19 viruses originated in bats then transitioned in an intermediate host before jumping to humans (reviewed in [5, 6]). The SARS-CoV-2 virus shares similar sequence identity to the SARS virus (SARS-CoV) and may provide insight into the current pandemic and cytokine storm. 

SARS-CoV-2 binds ACE2 receptors more efficiently than the SARS-CoV 2003 strain but less efficiently than the strain first identified in 2002, as mutations in SARS-CoV created a less virulent form. It is too early to tell how or if any mutations in SARS-CoV-2 will affect infection and mortality rates. The reproductive number (R0), number of cases directly generated by one infected individual, as well as complication and mortality rates for SARS, MERS and COVID-19 is listed in Table 1. While the infection rate of COVID-19 is much greater than SARS and MERS, the mortality rate is expected to be lower. On the other hand, ARDS-specific complication of COVID-19 is anticipated to be similar to SARS and MERS. 

Table 1. Virulence of SARS, MERS & COVID-19

Characteristics SARS MERS COVID-19*
Reproductive number (R0)  1.7 – 1.9 <1.0 2.0 – 2.5
ICU admission (% cases) 23 – 24% 53 – 89% 24%
ARDS-specific complication (% cases) 20%  20 – 30%  18 – 30% 
Mortality rate 14 – 15% 35% 2 – 4%

Adapted from [5-7].  *Current estimated values.  

 

A key lesson learned from previous outbreaks is how Coronaviruses commandeer the host cells immune response unleashing the cytokine storm. Both SARS-CoV and MERS-CoV encode accessory proteins known to antagonize IFN and suppress its signaling [8]. Diminished IFN response, allows for unchecked and rapid viral replication in which a surge of cytokines and chemokines are eventually and robustly released in a last ditch attempt to kill the virus contributing to the cytokine storm. Moreover, this dampening of the IFN response is strongly associated with disease severity [9].   In a second strike, the SARS-CoV virus also encoded accessory proteins that activate NLRP3 inflammasome, which drives IL-1β and promotes expression of other pro-inflammatory cytokines such as TNFα and IL-6 (reviewed in [6]). These strategic viral battle maneuvers are postulated to contribute to the cytokine storm that is being observed with the current COVID-19 pandemic.


The Next Wave: Kawasaki Disease-like Symptoms in Children

While early reports suggested that children were spared from COVID-19, a number of significant severe COVID-19 cases in pediatric populations have emerged [10, 11].  More urgently, is the rise of multisystem inflammatory syndrome in children (MIS-C) clusters arising in the US and EU associated with COVID-19. As of May 12, 2020 there were over 50 cases reported in New York City alone. With the current situation escalating rapidly, on May 14, 2020 the CDC issued a health advisory for MIS-C.  The disorder is associated with active infection or antibodies against SARS-CoV-2 [12], or COVID-19 exposure within 4 weeks prior to the onset of symptoms. Clinically, MIS-C is defined as persistent fever, requiring hospitalization with multisystem involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological) and Kawasaki disease-like symptoms. 

Kawasaki disease is a rare, vasculitis disorder affecting young children that can lead to coronary artery aneurysm, thrombosis and sudden death if left unchecked. It is the leading cause of acquired heart disease in pediatric populations in developed countries. Disease diagnosis is established by presence of persistent fever along with four of five signs and symptoms; bilateral conjunctivitis, strawberry tongue and/or dried cracked lips, polymorphous exanthema, cervical lymphadenopathy, swelling of hands and feet. While the exact etiology is still not fully understood, it is thought that Kawasaki disease may arise from an infectious trigger (bacterial or viral), resulting in upregulation of the immune system in a genetically susceptible individual (reviewed in [13]). 

Kawasaki disease has been previously reported with acute viral infection of the respiratory system, resulting in dysregulated immune response as observed in with the cytokine storm [13]. A children’s hospital retrospective review of Kawasaki disease admission from 2009 to 2013 linked the disease with rhinovirus and parainfluenza and to a lesser extent human coronaviruses strains 229E, NL63, OC43 [14]. Therefore, it is conceivable that SARS-CoV-2 may represent the infectious trigger during the current crisis. Similar to the cytokine storm described above, Kawasaki disease patients also have remarkably increased CRP, IL-6, IL-10 and IFNγ [13], and potential involvement of an acute B cell response [15].  Indeed, the first case of Kawasaki disease with concurrent COVID-19 infection was reported in a 6-month old infant with elevated CRP. The patient also had a continuous fever, lack of appetite, mild congestion, and met the classic Kawasaki disease criteria [16]. In addition, RT-PCR testing confirmed positive result for COVID-19 infection. 

While the incidence of past Kawasaki disease cases tended to be seasonal and were more prevalent in Asian countries and Asian races in the US [13]. Genome-wide association studies have identified candidate loci [17], however the genetic factors contributing to pathogenesis of the disease are not fully understood. Moreover, it is still too early to determine if genetic susceptibility plays a role in the rash MIS-C observed in the current COVID-19 pandemic as children of many ethnicities have reported disease symptoms [12, 16]. 


Quieting the Storm: Immunosuppressant Drugs

Since disease severity appears to be driven by a cytokine surge, it suggests that anti-inflammatory treatments may quell the cytokine storm and improve disease prognosis.  During the SARS outbreak, immunosuppressants such as corticosteroids resulted in more harm than good and are therefore not recommended for the treatment of COVID-19 [18]. For that reason, clinicians are expanding their toolbox and looking to therapies targeting pro-inflammatory cytokine. Tocilizumab, a marketed IL-6 receptor antagonist, is indicated for CSR, and was recently reported to improve COVID-19 patient outcomes in a small open-label study in China. Further randomized controlled trials are now underway with Tocilizumab, as well as with other  direct IL-6 antagonists such as Siltuximab and Sarilumab and indirect inhibitors such as Ruxolitinib. Additional immunosuppressant drugs such as anti-IL-1 anti-IL-17, anti-TNFα are also currently being explored as potential treatment under the compassionate use authority or off-label, with randomized clinical trials starting soon.  A recent GlobalData* database search retrieved nearly 75 COVID-19 planned or ongoing trials with interleukin inhibitors. Moreover, there may be a role for novel anti-inflammatory drugs in COVID-19 treatment.  Across all stages of development, sponsors are promptly advancing their program to help the fight. In response and support of this effort, the FDA issued guidance for industry on developing treatment and preventative COVID-19 drugs. While, immunosuppressant drugs will not be a cure for COVID-19, only a vaccine or anti-viral drug can annihilate the virus, anti-inflammatory therapies can play an important role in reducing the need for ventilators and preventing mortality.  

For children presenting with classic Kawasaki disease criteria, treatment guidelines include intravenous immunoglobulin and high dose aspirin [16]. Refectory Kawasaki disease may be treated with corticosteroids, although this approach remains controversial due to the risks associated with steroids [13]. Alternative therapies aiming to suppress the pro-inflammatory state include TNFα inhibitors such as Infliximab, Abciximab and Etanercept. Overall, treatment with these anti-inflammatory drugs led to improved outcome, reduction in fever and reduced risk of coronary artery aneurysms (reviewed in [13]. It remains to be seen how TNFα inhibitors will be deployed in the current pandemic. 


Biomarkers beaming like a Lighthouse

Another area under intense investigation is the use of biomarkers. Cardiac biomarkers such as N-terminal pro-B-type natriuretic peptide (NT-proBNP) indicate cardiac stress can be useful to assess cardiac risk associated with Kawasaki disease. Furthermore, identifying early prognostic biomarkers of COVID-19 severity is important for clinicians to initiate therapy before critical care is needed.  Low lymphocyte count as well as the serum levels of D-dimers, ferritin, CRP and IL-6 may help stratify mild from severe cases [19, 20]. C-reactive protein (CRP), an acute-phase inflammatory protein synthesized by IL-6-dependent signaling and indicator of IL-6 bioactivity. CRP can be used to predict the cytokine storm severity and monitor IL-6 blockade efficacy [21]. Therefore, monitoring chemokines and inflammatory cytokines may not only be helpful to risk stratify for disease severity but also demonstrate target engagement and proof-of-mechanism for immunosuppressant and anti-inflammatory drugs in development. 


A Fleet of Bioanalytical Platforms 

In addition to measuring cytokines in serum, COVID-19 testing will help launch us out of social isolation.  A SARS-CoV-2 qPCR test can confirm the presence of the virus and antibody testing can determine if someone was already exposed and may have immunity to SARS-CoV-2. For clinical trials, it is important that these assays meet stringent validation criteria as well as demonstrate good sensitivity and specificity.  

Utilizing an advanced array of bioanalytical tools, Celerion provides full bioanalytical solutions for small and large molecule assays as well as genetic and cell-based assays. For the health and safety of our participants and staff, we provide COVID-19 testing at our Clinical Pharmacology Units in Lincoln, NE, Phoenix, AZ and Belfast, UK. These tests are validated and performed in our very own Bioanalytical laboratory.  Critical to the current pandemic, we offer analytically validated cytokine and chemokine assays utilizing a sophisticated automated electrochemiluminescence (ECL) platform. 

View our list of analytically validated COVID-19 biomarkers here: https://live-celerion.pantheonsite.io/2020/04/27/capturing-the-cytokine-storm-using-biomarkers-in-covid-19-trials 


Celerion is on Deck!

As a full-service CRO and leader in early phase drug development, Celerion is ready to serve our biotech and pharma partners develop life-saving treatments during these extraordinary times. Our mission is to focus every day on helping our clients get their drugs to market, so that they touch the lives of our family, friends and people in need around the world.


References

  1. Pedersen SF, Ho YC. SARS-CoV-2: a storm is raging. J Clin Invest. 2020.
  2. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020;395(10229):1033-4.
  3. Yang YS, C.; Li, J.; et al. . Exuberant elevation of IP-10, MCP-3 and IL-1ra during SARS-CoV-2 infection is associated with disease severity and fatal outcome. medRxiv. 2020.
  4. Moore BJB, June CH. Cytokine release syndrome in severe COVID-19. Science. 2020.
  5. Petrosillo N, Viceconte G, Ergonul O, Ippolito G, Petersen E. COVID-19, SARS and MERS: are they closely related? Clin Microbiol Infect. 2020.
  6. Fung SY, Yuen KS, Ye ZW, Chan CP, Jin DY. A tug-of-war between severe acute respiratory syndrome coronavirus 2 and host antiviral defence: lessons from other pathogenic viruses. Emerg Microbes Infect. 2020;9(1):558-70.
  7. Ruan S. Likelihood of survival of coronavirus disease 2019. Lancet Infect Dis. 2020.
  8. Wong LY, Lui PY, Jin DY. A molecular arms race between host innate antiviral response and emerging human coronaviruses. Virol Sin. 2016;31(1):12-23.
  9. Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic. Asian Pac J Allergy Immunol. 2020;38(1):1-9.
  10. Shekerdemian LS, Mahmood NR, Wolfe KK, Riggs BJ, Ross CE, McKiernan CA et al. Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. JAMA Pediatr. 2020.
  11. Mehta NS, Mytton OT, Mullins EWS, Fowler TA, Falconer CL, Murphy OB et al. SARS-CoV-2 (COVID-19): What do we know about children? A systematic review. Clin Infect Dis. 2020.
  12. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020.
  13. Agarwal S, Agrawal DK. Kawasaki disease: etiopathogenesis and novel treatment strategies. Expert Rev Clin Immunol. 2017;13(3):247-58.
  14. Turnier JL, Anderson MS, Heizer HR, Jone PN, Glode MP, Dominguez SR. Concurrent Respiratory Viruses and Kawasaki Disease. Pediatrics. 2015;136(3):e609-14.
  15. Lindquist ME, Hicar MD. B Cells and Antibodies in Kawasaki Disease. Int J Mol Sci. 2019;20(8).
  16. Jones VG, Mills M, Suarez D, Hogan CA, Yeh D, Bradley Segal J et al. COVID-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr. 2020.
  17. Elakabawi K, Lin J, Jiao F, Guo N, Yuan Z. Kawasaki Disease: Global Burden and Genetic Background. Cardiol Res. 2020;11(1):9-14.
  18. Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet. 2020;395(10223):473-5.
  19. Velavan TP, Meyer CG. Mild versus severe COVID-19: laboratory markers. Int J Infect Dis. 2020.
  20. Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis. Clin Chem Lab Med. 2020.
  21. Liu B, Li M, Zhou Z, Guan X, Xiang Y. Can we use interleukin-6 (IL-6) blockade for coronavirus disease 2019 (COVID-19)-induced cytokine release syndrome (CRS)? J Autoimmun. 2020:102452.

*GlobalData search: Infectious disease therapy area; Coronavirus disease 2019 (COVID-19) indication; planned, ongoing not recruiting, ongoing recruiting, ongoing recruiting by invitation trial status; L04AC Interleukin inhibitors ATC classification. Search date 01May2020. GlobalData, John Carpenter House, UK.


Acknowledgments

Thank you to Celerion scientists Aernout van Haarst, Sumit Kar, Fred Pritchard, Michelle Combs and Lorraine Rusch for editorial assistance.

Sumit KarBy Sumit Kar, Lead Scientist – Biomarkers, Celerion

Cytokine biomarkers are released in the body after SARS-CoV-2 viral particles are presented by antigen presenting cells initiating a cytokine storm.1 Cytokine storm, known clinically as haemophagocytic lymphohistiocytosis or cytokine release syndrome, is mostly seen after viral infections, and leads to constant fever, increased ferritin, and multi-organ failure including acute respiratory distress syndrome (ARDS). For this reason, anti-inflammatory drugs, such as some targeting IL-6, are being tested as therapies for COVID-19 to prevent ARDS, the most common reason for fatality in patients suffering from COVID-19.

SARS-CoV-2 studies show alterations in serum IL-2, IL-6, IL-7, granulocyte-colony stimulating factor, IP-10, MCP-1, MIP1-α, and TNF-α, which are positively correlated with COVID-19 disease severity.1 The exact cytokine profile varies between studies. In previous viral challenge trials with neutralizing antibody therapies (e.g. for influenza), only IP-10 and IFN-g were reduced after drug dosing.2 The specific cytokines needed for SARS-COV-2 trials are yet to be well-characterized. Therefore, larger multiplex panels measuring several markers together are recommended for speed – especially those that are well characterized for reliability (e.g. Meso Scale Discovery® (MSD) V-Plex Assays).


Use Cases of Cytokines for COVID-19 Clinical Trials

These cytokine biomarkers can be monitored in SARS-COV-2 trials for vaccines, antivirals, and antibody therapies. Cytokines can be measured for patient enrollment, mechanism of action, and treatment effect contexts of use. For example, drugs trying to prevent ARDS should measure cytokines as a secondary endpoint and to show their mechanism of action. At Celerion, we validate all biomarkers fit-for-purpose based on their context of use in the study following the latest regulatory guidelines.


Celerion’s Cytokine Assays

At Celerion, we have validated MSD Cytokine Panels with up to 10 cytokines and chemokines for quantification via automated electrochemiluminescence (ECL). The panels can be custom designed according to need while maintaining the performance of the assay.

Celerion MSD Validated Cytokine Panels (human serum)
Panel 1: IFN-g, IL-1b, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, TNF-a
Panel 2: Eotaxin, Eotaxin-3, IL-8, IP-10, MCP-1, MCP-4, MDC, MIP-1a, MIP-1b, TARC
Panel 3: GM-CSF, IL-12/IL-23p40, IL-15, IL-16, IL-17A, IL-1α, IL-5, IL-7, TNF-β, VEGF-A

Exploring Cytokine Profiles in other Matrices

Respiratory specific matrices (i.e., bronchoalveolar lavage fluid (BALF), sputum and saliva) can be a reservoir of cytokine upregulation upon viral exposure via inhalation.3 Celerion has extensive experience measuring biomarkers in these respiratory matrices using the latest technology, which quantitates cytokines at ultra-low concentrations via Quanterix® Simoa and MSD S-Plex platforms.

References

1. Mehta P, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. The Lancet. 396(10229), 2020

2. McBride JM, Lim JJ, Burgess T, Deng R, Derby MA, Maia M, Horn P, Siddiqui O, Sheinson D, Chen-Harris H, Newton EM, Fillos D, Nazzal D, Rosenberger CM, Ohlson MB, Lambkin-Williams R, Fathi H, Harris JM, Tavel JA. Phase 2 randomized trial of the safety and efficacy of MHAA4549A, a broadly neutralizing monoclonal antibody, in a human influenza a virus challenge model. Antimicrob Agents Chemother 61:e01154-17, 2017

3. Horiuchi T, et al. Biomarker profiles of BALF in ALI/ARDS due to pandemic (H1N1) 2009 influenza. European Respiratory Journal. 38 (Suppl 55), 2017

Acknowledgements

Special thank you to Celerion scientists Curtis Sheldon, Amanda Daugherty, and Aernout van Haarst for their editorial assistance.

In the therapeutic toolbox, there is a multitude of drug categories. For decades, small molecules have been the cornerstone of pharmacology. In recent years, biological products have ushered in a wave of therapies, and forged the path for other cell- and genetic- based treatments. Greater understanding of the microbiome in association with dysbiosis and associated diseases have led to the advancement of pharmabiotics.

How Microbes can Treat Diseases

Pharmabiotics or live biotherapeutic products (LBP) refers to live microbes administered to patients to treat a disease. Gut dysbiosis is an imbalance of digestive track bacteria species that may contribute to a host of diseases including depression, Alzheimer’s disease, diabetes, irritable bowel disease (IBD) and nonalcoholic fatty liver disease (NAFLD) and even cancer.  Replenishing the so-called “good” bacteria may return balance and revert or alleviate symptoms of the conditions. Gut-brain-, gut-lung- and gut-liver- axes research has expanded our understanding of the microbiome and fostered a new branch of drug development. Dysbiosis has also been described in other organ systems such as the skin, mouth, vagina and placenta [1], all which may benefit from LBP treatment.

Pharmabiotics are validated through clinical trials with safety and efficacy endpoints for a given indication and follow the same regulatory pathway to approval as other novel drugs. In that respect, pharmabiotics differ from prebiotic and probiotic products. Prebiotics are fermented fibers that supports the growth of certain gut bacteria, while probiotics are live microorganisms that support or show potential for health benefits. For the most part, these two products are considered a dietary supplement or a medical food and do not require FDA premarket approval.

LBP can be derived from a human host or genetically modified or engineered to express a specific trait. According to ClinTrials.gov several LBP are in development [2]. This includes pharmabiotics for cancer adjuvant therapy, asthma, IBD and prevention from recurrent infection such as Clostridium difficile and bacterial vaginosis.

FDA Guidance on Pharmabiotics

The FDA defines LBP as a product that [3]: i) contains live organisms, such as bacteria; ii) is applicable to the prevention, treatment, or cure of a disease or condition of human beings; and iii) is not a vaccine.

The FDA guidance, which was updated in 2016, outlines requirements for describing the LPB and the manufacturing process as well as adjuvant substances if necessary. For non-clinical studies, the FDA recommends pharmacological and toxicological studies of the LBP in laboratory animals, or in vitro, to support a proposed clinical trial evaluating the investigational LBP. Similar to small molecule or biological drug development, non-clinical studies for LBP may include general toxicity; target organs or systems of toxicity; teratogenic, carcinogenic, or mutagenic potential of any ingredient in the product; and relationship of dosage and duration to toxic response and pharmacological activity. In addition, during early clinical Phase I studies, emphasis should be placed on subject safety. Early studies with healthy volunteers can be important to identify common LBP-associated adverse events before proceeding to studies in more vulnerable populations, such as those with the disease of interest. Currently, there is no EMA guidance for pharmabiotics as the agency does not regard LBP as a drug; however this stance may change as the field continues to grow.

LPB Dosing and Monitoring

Commonly, dosing units for LPB are based on a colony forming unit (CFU). According to the FDA, CFU is the measurement of viable microbial cells that are capable of replicating on agar plates and forming colonies which are then counted [3]. Depending on the targeted tissue, delivery of LBP may be orally ingested, administered via the urogenital track or other methods.

While traditional PK assessments may not apply to the field of pharmabiotics; microbiota diversity, taxonomic composition as well as the microbiome are important pharmacological endpoints. LPB bacterial strain colonization in stool and fecal metabolomic profile, including short chain fatty acids and bile acids, may be evaluated for LBP targeting gut disorders, while sputum may be obtained for microbe count and bacterial DNA for an asthma indication. Supporting serum biomarkers such as inflammatory cytokines, chemokines, and hormones can also demonstrate systemic pharmacodynamic changes.

Safety Considerations

While probiotics are generally considered safe for consumption, there has been reported instances of adverse events which can include systemic infections, deleterious metabolic activities, excessive immune stimulation in susceptible individuals and gene transfer [4].  Pharmabiotics may results in similar adverse effects, therefore close monitoring may be warranted. An excellent recent invited review by LeBegue et al. describes the history and study design considerations for pharmabiotic products [5].

The Celerion Advantage

Celerion clinics have experience with LPB and the unique challenges in sampling and handling key matrices such as feces, urine, sputum and other fluids for pharmabiotic studies. Our team of highly skilled Regulatory and Drug Development Service associates can support your LBP from IND through Phase II. In addition, we have a vast database of healthy volunteers as well as access to patient populations such as asthma, NAFLD and irritable bowel disease patients.

References

  1. Belizario JE, Napolitano M. Human microbiomes and their roles in dysbiosis, common diseases, and novel therapeutic approaches. Front Microbiol. 2015;6:1050.
  2. ClinTrials.gov. Live biotherapeutic products search. https://clinicaltrials.gov/ct2/results?cond=&term=live+biotherapeutic+product&cntry=&state=&city=&dist= Accessed March 9 2020.
  3. Early Clinical Trials With Live Biotherapeutic Products: Chemistry, Manufacturing, and Control Information; Guidance for Industry. . Food and Drug Administration; 2016.
  4. Doron S, Snydman DR. Risk and safety of probiotics. Clin Infect Dis. 2015;60 Suppl 2:S129-34.
  5. LeBegue CE, Love BL, Wyatt MD. Microbes as Drugs: The Potential of Pharmabiotics. Pharmacotherapy. 2020;40(2):102-6.

 

COVID-19 Vaccines in Development

COVID-19 is a respiratory illness caused by a novel coronavirus. According to the CDC, symptoms may include fever, coughing and shortness of breath. The virus is highly contagious and can spread between people who are in close contact with one another (within 6 feet) or when an infected person coughs or sneezes spraying respiratory droplets.

While the world is grinding to a halt to slow the spread of the COVID-19 through social-distancing, self-isolation and quarantine efforts. The race to find a COVID-19 vaccine has just began. As of March 18th 2020, there are 298 clinical trials for COVID-19 and 129 drugs in the pipeline which may potentially treat this disease (GlobalData).

As we face this ever-growing pandemic, Celerion is ready to work with our pharma and biotech partners to ensure safety and efficacy of COVID-19 vaccine development. Celerion is a leader in vaccine development with infections disease experience. Our track record spans both preventive and therapeutic vaccines, subunit and conjugates across all phases I-IV in more than 20 countries, 300 study centers and 4500 subjects.

We will get through this, together!!

 

Biological therapies such as peptides, enzymes and antibodies have changed the face of medicine, providing crucial treatment for a number of devastating inflammatory, endocrine and oncological diseases. However, these drugs often come with a hefty price tag due to the complicated nature of manufacturing biological products which are derived from living systems. In an effort to reduce drug prices, especially among biologicals, the Biologics Price Competition and Innovation Act was passed in 2010, creating a regulatory framework for biosimilar drugs to advance on to the market.

Biosimilars are not an exact copy but are similar to the originally approved biological product. While innovator products must demonstrate pharmacokinetic (PK), dose finding, efficacy, safety and clinical benefit/risk for approval; a biosimilar product follows an abbreviated pathway and must demonstrate equivalent PK, toxicity, similarity, and no clinical change compared to the innovator. With this framework, the goal is to introduce cost-effective alternatives to innovator biological drugs that can help improve patient access to these treatments.

The Biosimilar Model:
Robust, vigorous analytical characterization, justification of cell lines, examination of post-translation products, and preclinical studies are emphasized in the biosimilar paradigm. Most biosimilar programs only require one Phase I or III study, reducing cohort sizes and study time from traditional drug approval processes. Immunogenicity data must be collected in patients, however this can be descriptive in nature and is not required to be powered.

In lieu of a comparative efficacy study, pharmacodynamic (PD) biomarkers related to the mechanism of action can be evaluated as a study outcome. For example, picture a biosimilar product like recombinant insulin binding to a cell receptor to initiate a chain of signaling events. PD biomarkers such as glucose concentrations from these early events of the signaling cascade tend to be more sensitive, while late PD biomarkers like HbA1c are related to clinical outcome yet tend to have lower sensitivity. Therefore, early PD biomarkers are recommended as they are apt to illustrate how a drug behaves and can be applied to simulate PK/PD dose response. Both PK and PD biomarkers are required to be within margins to show equivalency, for the FDA these margins are 80-125%. When no good PD biomarker is available for an indication, clinical endpoints should be the same as the innovator product.

The FDA’s Action Plan:
While the EU has benefited from biosimilars for close to 15 years, with 45 approved products and marked reductions in drug prices [1], the US has been slow to embrace this technology. To date, 19 biosimilars have been approved in the US, however 7 products are still not on the market mainly due to patent litigation [1]. In an effort to cut-red tape, increase drug competition and reduce prices for patients, the FDA released their Biosimilar Action Plan in June 2018. This plan outlines their four-pronged approach to expedite biosimilar product development through; increasing efficiency in the approval process, clarifying regulatory guidance, providing educational support for patients and prescribers, and supporting market competition. Progress towards these goals is evident through 60 biosimilar development programs, a newly released final guidance for interchangeability, and plans to license biosimilar and interchangeable insulin products.

Optimizing Biosimilar Product Development:
The following study design recommendations are aimed to optimize biosimilar programs when planning for multiple authorities or indications, or for interchangeability designation.

Multiple Jurisdictions – Consider a 3-way crossover study with US and EU innovator and reference product to establish bridging for various markets.

Extrapolation – Consider running the study in the most homogenous patient group, this will improve sensitivity. Once approved for one indication, approval can be extrapolated to all other approved indications with justification based on totality of evidence.

Interchangeability– Refers to pharmacists switching between products without the consent of the prescriber. In the EU, interchangeability of a product is dictated by member states. Elsewhere, Australia has recently granted interchangeability designation for adalimumab biosimilar products [2] . In the US, interchangeability of a biosimilar should be demonstrated in a randomized two-arm (switching vs non-switching) clinical study with a reference product lead-in period. In a crossover design, the switching arm should have at least 2 or more product switches. One major challenge with interchangeability study design is that many antibody biosimilars have long half-lives and which would require a long cross-over study. However, the added statistical power of the cross-over design may well be worth the long study duration. In addition, during such trials, it is important to closely monitor for safety and adverse immune responses. Alternative approach is an integrated study design to demonstrate no clinically meaningful difference between reference and the biosimilar product and evaluate the impact of switching.

Turn-key Solutions for Biosimilar Programs:
As a global leader in analytical and clinical studies for biological drug development, Celerion provides turn-key solutions for a number of biosimilar programs.

Adalimumab – Anti-TNFα biological for the treatment of arthritis, plaque psoriasis, ankylosing spondylitis, Crohn’s disease, and ulcerative colitis
Rituximab – CD20 antagonist for autoimmune diseases
Teripartide – Recombinant human parathyroid hormone for osteoporosis
Ustekinumba– IL-12/23 inhibitors for psoriasis
• See our full list of validated bioanalytical assays at www.celerion.com/assays

Conclusion:
Altogether, biosimilars are primed to make a significant impact on access to vital medicines worldwide. Currently, of the marketed biosimilar products available in the US the cost for these products is an estimated 17-57% less than the originator price. With new, efficient tools to support biosimilar development, the FDA aims to see even more meaningful impact on drug prices.

References:
1. Sarpatwari A, Barenie R, Curfman G, Darrow JJ, Kesselheim AS. The US Biosimilar Market: Stunted Growth and Possible Reforms. Clin Pharmacol Ther. 2019;105(1):92-100.
2. JULY 2018 PBAC MEETING –POSITIVE RECOMMENDATION. https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2018-07/positive-recommendations-07-2018.pdf. Accessed 2 April 2019.

Chronic obstructive pulmonary disease (COPD) describes a cluster of diseases linked to breathing problems and airflow blockage, such as emphysema and chronic bronchitis. COPD is often associated with cigarette smoking, and prolonged exposure to poor air quality or toxic gaseous pollutants. This chronic disease affects over 3 million people in the US each year, and is currently the third leading cause of death worldwide. COPD results in difficulty breathing due to limited airflow availability in the lungs, and symptoms include shortness of breath, wheezing or chronic coughing. Periods of sustained or severe COPD episodes are referred to as exacerbations.  While there is no cure for COPD, current treatments increase bronchodilation (opening of the airways) to provide symptom relief.  For nearly 50 years, bronchodilators such as beta-2-adrenoreceptor agonists and muscarinic antagonists have been at the cornerstone of COPD treatments and are available in; short-acting, long-acting, single-, dual- or glucocorticoids combined triple-therapy.

Over the last decade, a surge in COPD research has greatly expanded our understanding of the disease and the key inflammatory players involved in airway blockage. This global initiative has led to the clinical development of over 25 novel drug targets. Roflumilast, a phosphodiesteratse type 4 (PDE4) inhibitor, was the first approved COPD add-on therapy which specifically targets the inflammatory processes underlying COPD.  Ongoing research has identified pivotal roles for neutrophils and eosinophils (inflammatory cells) in COPD development, and resulted in a number of exciting drug targets in the pipeline. By addressing the underlying mechanisms responsible for disease development, this may lead to treatments that alter the course of disease progression and possibly a cure for COPD.

Along with new drug targets, the COPD biomarker landscape has also changed. While spirometer and patient-reported outcome remain critical clinical study endpoints, a role for soluble biomarkers to characterize patient populations and demonstrate drug efficacy has emerged. Fibrinogen is a soluble biomarker drug development tool approved by the FDA for COPD patient selection. Plasma fibrinogen levels are elevated in patients with COPD and are likely to experience an exacerbation, a key inclusion criteria for clinical trials aiming to demonstrate a reduction in exacerbation rates. In addition, validated assays for pro-inflammatory cytokines such as TNFa, IL-5, IL-8 and IL-17 are also of interest as increased levels of such cytokines may reflect an upregulation of neutrophilic and eosinophilic immune cell activity, and their attenuation can be indicative of reduced inflammation. Moreover, these biomarkers can be measured in either serum or right at the site of the airway blockage and inflammation, in lung fluid. Sputum collection (coughed up saliva and mucus mixture) and bronchoalveolar lavage (BAL) are two manners to retrieve lung fluid secretions. BAL is a minimally invasive endoscopic technique performed by a trained bronchoscopist to obtain cellular and biochemical components from lung fluid during a saline wash. Various cell types, cytokines and drug concentrations can all be measured to better understand pharmacokinetic – pharmacodynamic relationships.

With the development of new technologies and more sensitive bioanalytical assays, novel, non-invasive breath tests have entered the investigational scene in recent years. For instance, methodologies have been applied in exploratory clinical studies to analyze volatile organic compounds (VOC) in breath,  exhaled breath condensate (EBC), and particles in exhaled air (PExA). Due to the nature and origin of VOCs which are derived from the entire body and microbiome, metabolomic analyses of VOCs have been explored as a potential tool to support early diagnosis of a broad range of systemic diseases, but it may also be useful for respiratory disease. For instance, VOC biomarkers have been shown to correlate with sputum markers from inflammatory cells and cell counts in COPD.  Distinct patterns have also been associated with COPD disease staging. In contrast to VOC, EBC and PExA analytes are considered respiratory tract-specific, reflecting airway lining fluid and immune cell mediators from the lower airways. Their analysis allows identification and quantification of inorganic anions and cations, proteins, lipids and genes known to play a role in immune response. In addition, drug concentrations can be assessed in EBC and PExA samples.

Altogether, novel biomarkers and non-invasive breath test technologies may help diagnose respiratory pathologies, identify pathogens and distinguish treatable traits. Moreover, these innovations in COPD may provide new insights into inflammatory pathways in relation to pulmonary disease and disease stages. Finally, novel biomarkers in exhaled breath are likely to provide new tools to monitor disease state and treatment effects for specific drug targets.

Links:

Third leading cause of death – https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death

Roflumilast – https://www.daliresp.com/

Drug development tool – https://www.fda.gov/ucm/groups/fdagov-public/@fdagov-drugs-gen/documents/document/ucm453496.pdf

Validated assays – https://live-celerion.pantheonsite.io/category/assays

Bronchoalverolar lavage (BAL) –  https://www.celerion.com/news/2013/01/09/bronchoscopy-suite

COPD disease staging – https://goldcopd.org/gold-reports/

 

 

Nonalcoholic steatohepatitis (NASH) is a chronic liver disease that affects over 17 million Americans and this number is growing. NASH can lead to cirrhosis, end-stage liver disease, liver transplant and even hepatocellular carcinoma.  Therefore, the need for treatment for this devastating, progressive disease is dire. That said, the NASH drug development landscape is robust. With over 100 compounds in discovery, nearly 80 drugs in clinical trials in which 4 have made it to Phase III; it is anticipated that a NASH drug will be available within the next few years and there will be several drug categories to boot.  Potential drug classes include those that target metabolic pathways such as de novo lipogenesis, those that have anti-inflammatory or anti-apoptotic properties and anti-fibrotic compounds. Similar to the diabetes indication, polypharmacy may be one strategy to tackle this progressive, chronic disease.

Although the NASH pipeline is abundant, with no FDA approved treatment as of yet, there is still time to enter the race. For sponsors considering stepping into the ring, here’s a list of suggestions to navigate the course.

  1. Develop the right plan for your drug.

Demonstrating safety and tolerability in early clinical studies is a must to advance a program forward, but so much more can be captured in these early trials. Pharmacodynamic signals of drug efficacy can be examined in Phase I development through innovative and adaptive study designs which include a patient arm or tailored proof-of-mechanisms studies, like interrogating the de novo lipogenesis pathway for an anti-steatosis drug.

  1. Identify the right participants for your study.

Participant pre-screening efforts can save sponsors time and money. A clinical research organization with a rich database of well characterized participants can expedite study recruitment and reduce screen failures. The FibroScan® is a fast, painless, non-invasive ultrasound-like device that measures liver stiffness (fibrosis) and hepatic steatosis (fat); both measures are key markers for NASH clinical trials. FibroScan® pre-screening can assist with participant selection for more sophisticated and expensive inclusion criteria such as magnetic resonance imaging (MRI) or elastography (MRE).  In addition, the Liver Forum, a consortium of academic leaders, industry and regulators, has recently recommended using the FibroScan® as part of the inclusion criteria for early phase NASH clinical studies.

  1. Do more with less.

The FibroScan® is not only a valuable tool for study inclusion criteria, this technique has served as a key primary or secondary study endpoints in many NASH clinical studies. Additionally, soluble biomarker panels such as FIB4 and NAFLD Fibrosis Score calculated from clinical chemistries such as AST and ALT, are also inexpensive ways to identify potential participants for clinical studies and monitor drug efficacy.

  1. Look towards the future.

Current NASH standards of care and management strategies include vitamin E or pioglitazone treatment as these therapies have been shown to be effective in improving the histological features of NASH. Drug-drug interaction studies may be necessary before moving into later phase studies to accommodate patients on standards of care treatment and allowing for a great patient population base to pull from, if safe to do so.

The NASH race to market is well underway; however latecomers entering the NASH indication do not need to fall by the wayside. A strategic early phase drug development plan may help foster the next blockbuster treatment.

Links:

De novo lipogenesis: https://live-celerion.pantheonsite.io/wp-content/uploads/2016/09/Celerion_Clinical-assessement-of-hepatic-DNL-in-NAFLD-review_092716-1.pdf

FibroScan: http://www.fibroscan.com/en/

Liver Forum: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5906171/

Management strategies: https://doi.org/10.1002/hep.29367

Drug-drug interaction: https://live-celerion.pantheonsite.io/service/pharmacokineticspharmacodynamics-pkpd

Injectable medication can be burdensome for the patient, causing pain and discomfort, and can contribute to compliance issues especially when chronic treatment is required. A promising and emerging area in pharmacology that may alleviate these obstacles is transdermal microneedle drug delivery. Patch microneedles are about the size of a postage stamp and can contain ~30-50 tiny needles smaller than the diameter of a strand of hair. This innovative design limits pain, tissue trauma and infection, and could be applied by minimally-trained personnel, facilitating use in both developed and developing countries.

Patch microneedles are widely gaining traction in the vaccine drug development space.  The microneedles penetrate the upper skin layer and rapidly dissolve to deliver the vaccine. Transdermal vaccine delivery is a preferred alternative for those with a fear of needles and is an essential step towards disease eradication worldwide.  A critical issue concerning current vaccines reaching rural regions is the lack of refrigeration and a cold supply chain. In this respect, microneedles hold the potential to overcome vaccine wastage due to heat and light exposure as well as volume waste.

This technology is not only being applied to vaccines but across indications from oncology to chronic diseases such as diabetes. Alarmingly, the World Health Organization estimates that only half of all patients with chronic diseases comply with treatment recommendations.  Microneedle patches are being developed to address treatment compliance by easing the burden of daily or weekly injections.  Through passive drug diffusion, drug delivery could be sustained for 6 months up to 1 year as fixed needles swell within the skin layer to hold the patch in place.

Microneedle patch technology is a promising drug delivery system that may ease patient burden and can facilitate great treatment compliance. A number of current studies in early clinical drug development are underway for a multitude of disease indications. This drug delivery technology has the potential to revolutionize access to treatment, making significant impact on public health worldwide.

Know Your Numbers Campaign

At Celerion, our community outreach does not only serve to inform the public about who we are and medical research opportunities, but we also use this time to give back to our community. In April 2016, Celerion launched a “Know Your Numbers” campaign in the Phoenix, AZ area. Through this initiative, we provide free hemoglobin A1c health checks at local community events.

Hemoglobin A1c reflects blood glucose levels over the past 2 to 3 months. This number helps an individual know if they are in a healthy range; falling in a prediabetes range, indicating risk of developing type 2 diabetes; or if they have diabetes, how well their medication is controlling their glucose levels. In the Phoenix area, the prevalence of type 2 diabetes is estimated at 10.8%, this is considerably higher than the national US average of 9.4%. In addition, the number for prediabetes rates is also startling.  According to the CDC, one-in-three people have prediabetes yet only 1 out of 10 know this, making diabetes prevention and awareness essential for our community.

Since the start of this initiative, Celerion has provided 1389 free A1c health checks across 24 events with 14 local community partners.  Results from the health checks have been recently published in the journal Trials and shared with our community partners, to aid them in developing strategies to best assist those at risk of developing type 2 diabetes. For our efforts to promote prediabetes and diabetes awareness, Celerion have been recognized by the American Diabetes Association, Maricopa County Health Department, and The Arizona Partnership for Immunization.

References:

National Diabetes Statistics Report, 2017. Estimates of Diabetes and Its Burden in the United States. Atlanta, GA: Centers for Disease Control and Prevention; 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf.

American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33 Suppl 1:S62–9. https://doi.org/10.2337/dc10-S062.

Hyperlinks:

https://live-celerion.pantheonsite.io

https://live-celerion.pantheonsite.io/wp-content/uploads/2017/07/Celerion_The-Impact-of-Prediabetes-on-Early-Clinical-Metabolic-Disease-Studies_F.pdf

https://bit.ly/2uVU5VD

 

 

 

 

 

Prediabetes, the New Normal in Early Clinical Research

There is a growing shift in inclusion criteria from healthy normal subjects to patient groups in early drug development. For programs with a chronic metabolic disease investigational product, prediabetes subject enrollment in early phase studies can facilitate the detection of efficacy signals and proof-of-concept [1].

Prediabetes describes a state of glucose impairment which holds a significant risk of developing type 2 diabetes. According to the CDC, 1 in 3 Americans have prediabetes, yet only 1 out of 10 individuals are aware of their condition [2]. Risk factors for prediabetes include being overweight or obese, an estimated 80% of subjects with glucose impairment are overweight or obese [3].  Additional risk factors include 45 years of age or older, a family history of type 2 diabetes, a sedentary lifestyle, and previously having gestational diabetes [2]. Clinical research organizations can provide a helping hand in managing the disease by being committed to raising prediabetes awareness through free A1c screening during community outreach events [4] and offering resources on diabetes prevention.

Type 2 diabetes patients can be vulnerable to hyperglycemic and hypoglycemic events during early phase placebo-controlled studies, monotherapy studies or during washout periods. Since prediabetes subjects maintain a degree of glucose control, they are less likely to experience severe glucose excursions. Therefore, a risk mitigation strategy to minimize serious glycemic changes in early dose escalation studies could include the enrollment of prediabetes subjects. In addition, to better understand a drug’s effect on glycemic parameters, intensive daily glucose tracking through continuous glucose monitoring (CGM) can provide blood glucose readings every 5-15 minutes for up to 2 weeks. To this end, CGM is recognized as the “ECG Holter-monitor for glycemia” [5].

Nonalcoholic fatty liver disease (NAFLD) is the next major health epidemic and prediabetes is strongly associated with hepatic inflammation and fibrosis in NAFLD subjects [6]. Nonalcoholic steatohepatitis (NASH), a deleterious form of the disease can lead to liver cirrhosis, end-stage liver failure and even hepatocellular carcinoma. Using non-invasive techniques to assess steatosis, inflammation and oxidative stress, and fibrosis can expedite clinical research. These pharmacodynamic imaging and soluble biomarker analyses are essential early signals of drug efficacy to enable faster go/no-go decisions.

Prediabetes subject enrollment in early clinical studies for weight management, Type 2 Diabetes or NASH indications offers an opportunity to examine pharmacodynamic endpoints in a population of interest while minimizing safety concerns typically observed with patient studies.

References

1. Paglialunga, S. The Impact of Prediabetes on Early Clinical Metabolic Disease Studies: Celerion, Technical Note. 2017.

2. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA. 2014.

3. Tuso P. Prediabetes and lifestyle modification: time to prevent a preventable disease. Perm J. 2014;18(3):88-93.

4. Jaycox SH, Esposito M, Paglialunga S. Effectiveness of Community-Based HbA1c Screening as a Clinical Study Recruitment Tool. American Society for Clinical Pharmacology and Therapeutics; 2017 April 17 Washington,DC.

5. Vigersky R, Shrivastav M. Role of continuous glucose monitoring for type 2 in diabetes management and research. J Diabetes Complications. 2017;31(1):280-7.

6. Yilmaz Y, Senates E, Yesil A, Ergelen R, Colak Y. Not only type 2 diabetes but also prediabetes is associated with portal inflammation and fibrosis in patients with non-alcoholic fatty liver disease. J Diabetes Complications. 2014;28(3):328-31.

Supporting the Next Major Health Epidemic

Non-alcoholic fatty liver disease (NAFLD)/Non-alcoholic steatohepatitis (NASH) is viewed as the next major health epidemic and with no current anti-NASH medication on the market to treat this chronic disease; it is expected to place a heavy burden on our healthcare systems.

NAFLD is considered to be a hepatic manifestation of metabolic syndrome, associated with obesity and insulin resistance. The incidence of NAFLD/NASH is rapidly increasing worldwide, currently affecting over 1 billion people, and the prevalence of NAFLD/NASH is not limited to adults as the rise of this disease is also observed in children. Presently, the standard of care for NAFLD/NASH includes invasive liver biopsy procedures for diagnosis and management. Therefore, NASH is expected to become the most common indication for liver transplantation in the United States by 2020, surpassing viral diseases like hepatitis C.

This month, Thomas Jefferson University Hospital in Philadelphia reported its 1,000th liver transplant surgery. This milestone calls out to our industry the importance of our work in support of patients with end-stage liver disease.

Non-invasive diagnostic and prognostic techniques to identify NASH patients and those who will positively response to a given treatment regimen is overwhelmingly needed. Recent advancements in medical imaging, such as magnetic resonance elastography and FibroScan, are contributing to achieving these goals. In addition, an emerging trend in early clinical research is to examine pharmacodynamic effects in patient populations. In this respect, imaging tools as well as soluble biomarkers found in bodily fluids such as blood, urine, saliva, etc. are extremely useful to evaluate NAFLD/NASH drug efficacy.

A number of pharmaceutical companies are currently involved in NAFLD/NASH research. This list includes, but is not limited to Intercept, Genfit, Galmed, Gilead, Genentech, Pfizer, Merck, and Novartis.

An experienced contract research organization (CRO) will have NAFLD/NASH capabilities and experience in hepatic lipid metabolism and fibrosis biomarkers to incorporate into drug development Single Ascending Dose (SAD), Multi-Ascending Dose (MAD), Drug Interaction (DDI), Phase 1b, Proof-of-Concept (POC) studies. The scientific and clinical operational staff will have experience and thorough understanding of the disease as well as bioanalytical and non-invasive measurements of hepatic lipid metabolism, inflammation and fibrosis. In addition, the CRO will have a strong recruitment track-record to support special-population studies like diabetes, obesity, NAFLD programs.

Celerion’s experienced and knowledgeable scientific and clinical operational team can help navigate NAFLD/NASH drug development programs through this emerging market.

Science leading to medicine, done well, helps saves patients’ lives and provides for a healthy standard of living.

Celerion was recognized by Biopharmaceutical Clients in May 2016 as a Leader in Contract Research Quality Benchmarking Survey.