Hope Now for ALS

There has been a lot of recent controversy surrounding the experimental treatment in clinical trials known as GM604. A lot of misinformation has been tossed around on both sides of the issue. I want to beg your attention for a little while to explain what's really going on.

First, as many of you know, I was the single late-stage PALS who received GM6 in compassionate use. The intent behind this was to get a look at differences in biomarker candidate levels between earlier-stage and late-stage PALS. Any outward physical manifestation of improved condition noticed would be a bonus and, due to my advanced condition, no improvement in condition was expected. Nevertheless, Genervon and I came up with the idea to try to chart improvements in the tongue. The rationale is that since my tongue is only moderately affected, and because the hypoglossal nerve contains one of the shortest motor neurons in the body, any possible improvement would be noticed there first.

Because of my growing cooperative relationship with Genervon dating back to my first blog post on GM6, I was granted the only Expanded Access outside of trial. They were interested in getting a look at GM6 behavior in late-stage PALS and I had proven to them my organizational skills in preparing my own medical surveillance team and in communications by preparing the mechanism for data capture. Even a single Expanded Access Program can be a burden on such a small company not optimized for such work. My knowledge and experience gained over the past few years was of considerable help in filling out and transmitting (and following up on) my own paperwork.

Thousands of single Expanded Access requests would be overly burdensome and even if Genervon enlisted the help of the ALS Emergency Treatment Fund, the maximum number of patients who would be able to participate would be measured in the few hundreds. Not only would patients have to pay for drug but would also have to pay for their own medical surveillance team and at least one hospital visit for the first infusion (this alone represents several thousand dollars). If you are required to give biological samples, the cost tops $10,000.

Genervon shared with me much of the top-level data from the Phase 2 to compare against my own data. Even though the trial population was small, the data were stronger in separation between treatment/placebo cohorts than in any legitimate trial results I had seen before. And GM6 was demonstrated safe over a much larger group spread over three different neurological diseases (including ALS) plus a healthy safety group. For these reasons I suggested to and worked with Genervon on applying for the FDA Accelerated Approval Program in order to get GM6 to all PALS paid for by insurance and Medicare.

And thus began the shitstorm...

Researchers, neurologists, and leaders of certain advocacy organizations who believe in the FDA's 60 year old regulatory formula - comprised of designing, completing, and analyzing Phase 1, 2, 3 trials over a period of 5-15 years - are failing in their proclaimed mission. They simply have to stop regarding patients as helpless victims willing to eat rat poison if someone said it cured ALS, Genervon as somehow the 19th Century snake oil salesman, and themselves as the White Knight riding to our rescue. The very process of obtaining an experimental drug requires a lot of medical oversight, which we appreciate and rely on. However, patients are intelligent adults whose only desire is to change the status quo of scientific research for the benefit of both the current and future generations of PALS.

The 1992 FDA Accelerated Approval Program (AAP) was designed to meet the needs of patient populations where there is an urgent and unmet need. In 2012, Congress passed and the President signed into law the Food and Drug Administration Safety and Innovation Act (FDASIA), strengthening the agency's ability to advance public health by equipping the FDA with tools intended to expedite the development and review of innovative new medicines that address certain unmet medical needs. Among the objectives, Title IX expanded the scope of products that qualify for accelerated approval. Specific language in this law states that the FDA is to incorporate novel approaches to the review of surrogate endpoints based on pathophysiologic and pharmacologic evidence in such guidance, especially in instances where the low prevalence of a disease renders the existence or collection of other types of data unlikely or impractical. It is obvious that Congress and the President had in mind diseases just like ALS when passing and signing FDASIA into law, yet the FDA has done very little to incorporate these guidelines.

With Congress now discussing the 21st Century Cures Act, we at Hope Now for ALS believe that we are on the right side of history by insisting that PALS are given opportunities to access new investigational treatments through the FDA's Accelerated Approval Program which, with its requirement for post-marketing Phase 4 data surveillance to confirm efficacy and safety, will continue to provide invaluable data on new treatments for ALS. As most patients are ineligible for standard clinical trials, this is our only option to contribute to research that will provide the same data at a faster rate among a larger population of patients - providing much needed data on subsets of the patient population. The Phase 4 requirements of Accelerated Approval also have the ability to save billions of dollars in research that is better spent developing more new and better investigational treatments for a myriad of neurological conditions.

I will grant that the biomarker candidates are new and not yet "proven", but FDA did allow them as endpoints in the Phase 2. They are not brand-new fabrications by Genervon and are backed by a lot of recent research by respected researchers. And they were all quite uniform in response to GM6 while the placebo group all continued in the abnormal direction. In my n=1 case report the biomarker candidates sometimes went in the reverse direction, but ALWAYS TOWARD NORMAL LEVELS. This is a great indication that GM6 promotes neuronal homeostasis - the holy grail for ALS research.

The Phase 2 was indeed also only a very small population, and in previous ALS trials of similar size it was impossible to collect reliable efficacy data in such a small cohort. However, this trial was very different from previous trials. The effect registered was much larger than in previous such trials (especially dexpramipexole) and was backed up by multiple secondary measurements not subject to any placebo effect. The combination of surprisingly-large effect size and objective biological markers sets this aside from previous trials (which also used the ALSFRS almost exclusively). There was an erroneous though well-intentioned attempt to use the released FVC information as evidence of poor trial design. However, the comparison used a very inappropriate analogy population and was built on an assumption based on incorrect data.

I do have serious issues with a point used in arguments against GM6: The lithium debacle. The media reports which came out obviously created a lot of excitement within the patient community. Our first reaction was asking and pleading the research community to quickly follow up with more trials to confirm that study and the response from the research committee was absolute disinterest. Therefore the patient community took it upon themselves to create a verification study, which we did. We did *NOT* merely go out and start using lithium off-label. In fact, it was only after our trial data was being released that the research community decided to do a confirmation study. By then we had already demonstrated that lithium had no effect in ALS and begged the research community to not waste time and millions of dollars.

But again, the research community ignored the patient community.

The Hope Now for ALS movement isn't for GM6 to skip the regulatory process. It's to get FDA to use its existing programs and Congressional mandate to provide potentially life-saving treatment to PALS. This is especially important now that truly-effective treatments are very near (including NP001, Neurown, etc.). Caution is obviously warranted but ALS is a race against a clock that doesn't care. More aggressive strategy is thus required which necessitates a little less caution and a lot more courage.

In summary, the facts are:

• Genervon asked FDA for Accelerated Approval at the post-Phase 2 meeting where they presented the complete trial data plus the case report for my Compassionate Use project. I know this to be true because I co-wrote the cover letter to the data package and it specifically asked for Accelerated Approval (and it was me who urged Genervon to pursue AAP).
• The FDA should have responded with specific instructions on how to file. They did not and thus we were all left in a state of confusion. Then FDA took the unusual step of calling on Genervon to publicly release proprietary data. Genervon has no duty to do so and FDA has no authority to make such a request.
• Genervon has perfectly complied with law and regulation. All they want is to help and they believe GM6 can do that. The data so far looks good (and I can say that, having actually seen it where all others commenting otherwise have not). It's not a slam-dunk, but it's positive and safe enough that I think all PALS should have access to it - not just those eligible for clinical trial.
• The FDA Accelerated Approval Program, in place since 1992 to deal with fatal diseases for which no other treatments exist, is the best way to save lives. It opens access WHILE CLINICAL TRIALS STILL CONTINUE. It's used for cancer and other diseases with less-severe prognosis. Why not ALS?
• GM6 has a perfect safety record in over 50 patients across 3 separate neurological conditions plus a healthy initial safety cohort.
• This is about patients deciding for themselves what risk to take in treatment. This is NOT about a company trying to avoid the clinical trial process or enrich itself on patients desperation. The AAP is an existing program which gives patients access to potentially life-saving treatment while collecting the valuable efficacy data.
• Contrast Genervon's completely legal and transparent actions to other companies marketing unproven products such as lunasin and aimspro directly to patients using email. Those companies use slick pitches with "proof" based purely on non-accepted metrics and anecdotes.
• The movement behind GM6 is entirely grassroots.

The above are facts. All of the "expert opinion" going around is just biased speculation.

Scuttle Rebuttal

I am a little peeved at a new attack on the push for FDA's Accelerated Approval Program for the ALS treatment called GM6 (known as GM604 in clinical trials). This attack basically follows the same line as the one from the ALS Association (and in fact incorporated it by reference). Both are sloppy and disingenuous in style and content. They attempt false comparison to other previously-failed trials without including the reasons for those previous failures and they also try a very clumsy smear by comparison to an act of intentional clinical fraud. I am disappointed that such comparisons are presented to a public looking for facts as well as hope.

First let me discuss the false comparison to previous trial:

1. The comparisons are false primarily because the old trials exclusively used the ALS Functional Rating Scale (ALSFRS) which is a horrible metric by even the most generous interpretation. This is the only way a call for large trials can be justified, because the numb insensitivity of the ALSFRS (even the Revised version) requires such to make any kind of meaningful conclusion in a heterogeneous disease like ALS. However, the GM6 trial used several biomarker candidates and other objective clinical measurements as surrogate end-points (keep that phrase in mind) which correlated which the subjective end-points such as the ALSFRS-R. The biomarkers used were suggested and evaluated by Dr. Robert Bowser, a 2015 winner of the Sheila Essey Award for significant research contributions to fighting ALS.
2. Brain-Derived Neurotrophic Factor (BDNF), one of the neurotrophic factors listed in Dr. Dickie's post, doesn't cross the Blood Brain Barrier (BBB). It's almost impossible to get a therapeutic dose into the patient without an intrathecal infusion (directly into spine) using a pump over time. This has numerous obvious drawbacks. It's also very unclear whether a single neurotrophic factor is useful in ALS, which encompasses a host of deficiencies.
3. Cilliary Neurotrophic Factor (CNTF) does cross the BBB and early animal model tests indicated efficacy. However, two human trials in 1996 using subcutaneous delivery and intrathecal delivery as well as a review in 2004 revealed no efficacy in lower doses and serious side-effects at high doses. It's also important to note that the animal data came well before the excellent work ALSTDI did characterizing the extreme difficulties in using that model. Any ALS mouse data released prior to 2009 (and any subsequent found to not strictly follow those guidelines) should be considered suspect. I have personal knowledge of the difficulty in using this model and the false-positive data which can result from improper use.
4. Next, Insulin-like Growth Factor 1 (IGF-1) also crosses the BBB but has a very very short biological half-life, meaning it is broken down and excreted in a matter of hours. That makes therapeutic levels almost impossible to maintain. A form was created with a buffering agent attached to IGF-1 which roughly doubled the half-life but even that was woefully inadequate. Anyone who remembers the IPLEX debacle of a few years ago knows the story.

The comparisons to such single-target neurotrophic factors as BDNF, CNTF, and IGF-1 are therefore flawed in logic and fact. It is very disingenuous for Dr. Dickie to compare GM6 to them as GM6 is a master regulator and acts in 12 relevant pathways simultaneously. This information is already in the public domain freely available for anyone to look up.

Next, Dr. Dickie compares the GM6 results with those of the initial results of NP001 (actually he links to his own blog post where he addresses the anecdotal reports which came before the official results were published). What he failed to mention was the updated post-hoc analysis which showed a halt of disease progression in 27% of patients in the trial. Further, the analysis showed statistically significant evidence of two biomarkers which identified responding sub-groups. This is a tremendous achievement in ALS clinical trial history. Unfortunately the biomarkers aren't the same in the GM6 trial so the comparison of the two is incomplete at best. The only real similarity is that both trials used biomarkers as secondary end-points. However, the GM6 trial used them in a way that didn't require post-hoc analysis.

The comparison with lithium is especially troubling. First, it was far from "recent", with patient excitement starting in 2007. You can find the data collected in the first PALS-led and created clinical trial which coincidentally also involved lithium. What both ALSA and MNDA failed to report about the study which started the excitement ("Fornai, et al., 2008") was that the study essentially "cooked the books" by assigning PALS with slow progression of disease to the treatment group while putting the more standard PALS in the placebo group. This was revealed only after the paper was published. In the GM6 trial, run by two leading and internationally well-respected ALS researchers and clinicians, all participants were randomly assigned to receive either drug or placebo. The only way the comparison to the lithium study would be accurate is if the researchers deliberately placed certain patients in each cohort. Genervon merely supplied GM6. The trial was run and data collected by the two principle investigators (fancy name for doctors who run clinical trials). The analysis was then also done by a contract research facility. So any implication that Genervon somehow fabricated the data is false and besmirches the reputations of two prominent ALS doctors.

It must be noted and repeated that the standard FDA clinical trial practice is indeed extremely important in terms of protecting the public from the unscrupulous. The collection of objective scientific data is the foundation of good medical care. Nobody calling for the Accelerated Approval of GM6 disputes this. However, because ALS is so rapidly and uniformly fatal, we are calling for FDA to utilize the discretion it was granted in the face of an earlier similar crisis (the AIDS epidemic). Further, we call on everyone to realize that the GM6 trial used much more than the ALSFRS as a metric and thus smaller trial populations are much more statistically significant than before. The other end-points used in the Phase 2 are objective and not subject to placebo effect. Therefore, the indication of efficacy observed in the trial should be considered stronger than in previous trials which relied almost solely on the ALSFRS.

The Accelerated Approval Program was created to bridge the gap between the need for data and the urgent unmet needs of patients with rapidly-fatal diseases. The GM6 trial was unique in the strength of the preliminary efficacy signal, largely due to the objective biomarker end-points used. Just like the early days AIDS crisis, PALS have no meaningful treatment options and thus no hope. We want to use the very FDA program created to deal with that situation. We admit the need for more scientific data. But we don't want to die while it's collected.

Condition Green

As many of you might already know, I was the late-stage PALS mentioned in the recent Genervon press release. I got interested in this drug some time ago, did some research on it and wrote a blog post about it. I had contacted the company, Genervon, to get information for my post. Thereafter, a dialogue was maintained regarding clinical trial status and future development plans. Being that I am a late stage PALS and still extremely active in awareness, advocacy, and science, they agreed to my request for compassionate use. It was another 9 months going through the process of authorization (mostly because my local hospital had never done anything like this before and together we created a new protocol).

During that time the Phase 2A results came out and I was given access to some of the data. Those, combined with my own experience, gave me the satisfaction that this drug was safe and quite likely effective. I share the concerns about trial size, but like all PALS am concerned for the time required to go through the usual phases of clinical trials. The clinical trial program actually has four parts:

• Phase 1 - single dose usually in healthy subjects for gauging safety
• Phase 2 - use in actual patients looking at safety and initial efficacy
• Phase 3 - larger patient population with different doses, efficacy and SAEs
• Phase 4 - market surveillance for adverse events

Not only does it take time to fully enroll and execute a large clinical trial but it takes even more time to secure the funding necessary to begin each phase. This is especially true in this current era of venture capital avoiding biotech investment.

I have helped launch other initiatives to get PALS access to experimental treatments. It is critical that patients get more than one or perhaps two chances at early access to treatment while they are newly diagnosed. Drugs that are possibly effective must be made broadly available to patients who are facing otherwise-certain death. Based on the safety and the indication of efficacy in GM6 (mainly borne of my personal experience), I got behind the effort to seek what FDA calls Accelerated Approval so that many more PALS can try it and see where it takes us. Accelerated Approval requires full data surveillance for efficacy, not just serious adverse events (SAEs). The efficacy data determines whether final approval is made. Basically, Accelerated Approval is like a Phase 3 where patients/insurance pay for participation. I believe all PALS would gladly participate in such a program.

If the wider data don't support the continued use of GM6 I will be the first to admit it. But right now I believe GM6 has the capability to effectively treat ALS in a way no previous drug ever has. And I want to get that opportunity as quickly as possible to as many PALS as possible.

After publishing the press release and posting it on social media and online forums, another PALS started a petition to the FDA to demonstrate the support in the ALS Community for this Accelerated Approval. I would like to urge all who are concerned about ALS - PALS/CALS/Friends - to sign this petition and share it among your social circles. At that link you can sign the petition and post comments to be included with your name. You can also find links to email Senators who oversee FDA and proposed text for those messages.

It is imperative that the comments left on the petition signatures be respectful. FDA isn't the enemy. They really would like nothing better than to approve a treatment for ALS but need the data to support it. I think we have the data because even though the population was small, the slope of decline as measured by the ALSFRS-R was reduced significantly during the short treatment window. Also, certain biomarker candidates were tracked and correlated with progression. Nevertheless, FDA has to be very careful with the precedent it sets so we as patients must be partners with them in these decisions.

My own experience with GM6 has been positive. The worst part of the entire project was getting the PICC line and the lumbar punctures for CSF samples to make biomarker measurements. I experienced absolutely no adverse events related to the drug. Insofar as benefits, I must admit that the small gains in function noted in the press release are most likely due to surviving neurons branching out new axon terminals to cover the neuromuscular junctions (NMJs) abandoned by the dying motor neurons affected by ALS. GM6 will NOT regrow dead motor neurons. However, it does induce healing in injured ones. In my case, I probably don't have many injured motor neurons - most of mine are gone. But people who are more recently diagnosed have a higher chance of regaining some lost function in addition to stopping progression.

Based on the information I have seen and my own positive experience, along with the considerable (at best) delay in commencing a larger Phase 2 or 3 trial, I think GM6 deserves Accelerated Approval. I also think this could set a beneficial precedent for future drugs which show similar safety and efficacy signals in early trials. Hence my hope for GM6 getting into the larger population of PALS.

IceBucket The Blue Sky

The #ALSIceBucketChallenge has been nothing short of a miracle for patients and researchers. Internet memes are rather capricious, having a nearly random hit/miss ratio. That this became so huge is a stroke of incredible luck. The awareness, and resulting increase in donations, has been a huge windfall. This surge couldn't have come at a better time as researchers now have exquisite investigational tools not available even 5 years ago.

There is then the begged question, "Why did it take a patient and a tractor trailer full of luck to bring awareness to the public?" For decades there have been organizations claiming to represent ALS patients. Yet never has there been a sustained national awareness project executed. Patients were left largely on their own to create awareness. This is a question to which we as patients should demand an answer.

Nevertheless, the windfall is upon us. I believe that this boost in funding should be used to create a critical mass of awareness and outreach. As stated, Internet memes are capricious and subject to fading from the public memory with all the speed and ferocity with which it entered. This is the perfect time to keep the message sustained in the public view. Certainly the money to do so is now available.

Another question the ALS patient community should be asking is how much of the massively increased donations are going to be actually used for research, and in what programs. Some donations are going directly to research facilities but the bulk of them are not. Is that bulk to be hoarded and doled out in tiny slices and without focus to a wide variety of basic research projects, never giving any sufficient amounts to fully complete the work? Or will a significant effort be launched which will fund focused work on high-value pathways, including helping fund clinical trials in humans (there are a few promising treatments languishing for lack of funding to pay clinics to conduct Phase 2-3 trials).

This is the time for organizations representing the ALS patient community to step up. The shelf-life of popular public awareness is notoriously short. We need to take this opportunity to create a program of sustained awareness and lobbying for research funding, along with a focused research effort encompassing basic research through to human trials. It is also the time for all research and advocacy organizations to come together as a united front in order to make ALS nothing more than an unpleasant memory.

Eye Caramba!

I would like to urge all of my readers to immediately visit this Kickstarter project. So much better than potato salad, this device is a revolutionary step forward in personal portable Speech Generating Device (SGD) technology. It's wearable and allows eye contact with your conversation partner while using eyegaze.

DIG THE BEAUTY OF THIS DESIGN:

The keyboard and other controls are displayed right before your eyes. The generated voice comes from the glasses so it appears to come from you, creating a more natural conversation experience. You're outside in bright sunlight? No problem! The glasses come with pop-on shades and because the eye-tracking camera is inside, it's shielded from solar infrared glare. And best of all, the control unit is basically an Android-powered smart phone. This means superior portability and an open-source platform for future app development!

The man behind this innovation, Ivo Vieira, has a history of successful optical technology in satellites (his original company, Luso-Space, has a very exciting mission nearing launch to measure gravity waves with orbiting lasers). His father has ALS and is very disappointed with current eyegaze technology. Furthermore, we have met personally and I am very impressed not only with his development, but with his future plans to increase quality while decreasing costs. I am proud to recommend this project to you all. Please support this Kickstarter and help get the Eyespeak into commercial production ASAP.

Of Mice And Me

As many of my readers know, about two years ago I came across a study investigating a novel molecule for the treatment of Alzheimer's. The molecule, J147, is a synthetic derivative of curcumin. Curcumin and other similar molecules have long been under study for neurodegenerative diseases. Unfortunately curcuminoids have rather poor bioavailability, meaning they are quickly excreted from the body and require high amounts to have a therapeutic value. Like curcumin, J147 is "orally available" (meaning it is introduced to the body by eating it) but is more than 100X as potent. This means a much smaller quantity is necessary for therapeutic effect. So far, we haven't found a toxic dose of J147. Work on toxicity is ongoing.

In the Alzheimer's study J147 had remarkable results in that model. The pathways acted upon were quite relevant to ALS. These include potent antioxidant effects, significant reduction of microglia activation and migration, and reduction of heat-shock protein expression which indicates a shift back toward cellular homeostasis. More recent data (unpublished) indicates an effect in reducing astrocyte activation, which is sufficient to rapidly kill even healthy motor neurons.

Unfortunately, because J147 is pleiotropic, pharmaceutical companies weren't interested. The current research paradigm is to focus on single molecular targets. For diseases with a single mechanisms, that's a fine method of attack. But ALS has quite a few things going on simultaneously. All prior single-target treatments have failed and the current growing opinion is that successful treatment would require a cocktail of drugs. Better to have a single pleiotropic substance than a mixture of chemicals with uncertain interactions.

In April, 2013, I created SciOpen Research Group in order to have an entity capable of negotiating research and licensing of novel molecules with the promise of treatment of ALS. J147 is our first project. In the early summer of 2013, SRG applied to Prize4Life for access to their colony of G93A transgenic research mice at Jackson Laboratories. Our research proposal for J147 was accepted and we were given granted sufficient animal numbers to properly conduct our study. We received the mice and started the experiment at the end of January.

We are very excited to have commenced our first research program and demonstrate that guerrilla biotechs can perform quality science. To that end, we created a crowdfunding campaign on Indiegogo to obtain funding for the next step of the experiment - microscopic tissue examination. This will tell us exactly what J147 did to help the motor neurons in the mice.

Please donate if you can. All donations are tax-deductible. If you cannot donate please spread word about SRG and our need for funding this new and exciting research.

Pot Luck

An article appeared on social media about a group of parents using cannabidiol (CBD) for their children's epilepsy. Unlike the usual reports of people using marijuana and subjectively reporting "improvements", this group of patient advocates went and filed an Investigational New Drug (IND) with the FDA. Don't get me wrong - I support the medical (and recreational) use of marijuana, but heretofore the real scientific data available has been extremely thin. Rather than going on Silk Road to get a bunch of medicine then post wonderful stories on social media, this group created a real clinical trial in cooperation with FDA and a company named GW Pharmaceuticals which supplied a pure oil formulation of CBD. This is a very important development in patient-driven access to investigational drugs. Far better than the usual DIY projects (even the handful started by yours truly), this type of project can deliver real, verifiable, and scientifically-accepted results.

The body contains cannabinoid receptors both in the CNS and periphery. The most well-known cannabinoid ligand is THC (a CB1 agonist) which is responsible for the euphoric psychoactive effect in marijuana. Both natural and synthetic cannabinoids long been of interest in treating disease. What's of most interest in medicine are the anti-inflammatory effects of CB2 agonists such as cannabidiol or CBD. Endogenous CB2 receptors are upregulated in the spinal cords of SOD1 transgenic mice. CBD agonists show symptomatic improvement in several inflammatory diseases. There is evidence that CB2 receptors are upregulated in response to the inflammatory microglial activation in ALS. Several studies have shown that CB2 agonists have a beneficial effect in transgenic SOD1 mice. This data shows that more work, perhaps in in human patients, is warranted.

Alternative medicine is very popular in the ALS Community because, frankly, there is nothing currently available proven to extend the lives of PALS. Unfortunately most experiments are done without adequate objective observation and recording of data. Instead all that is reported are vague descriptions of improvement, skewing any rational perception of the particular alternative medicine. This causes more desperate patients to attempt the alternative with the same lack of adequate reporting.

This post, however, is not about calling for an IND for CBD (which would nevertheless be a good idea). The point here is to spotlight that a group of patients and/or advocates got together to do an experiment outside of an institutional clinical trial. They led the way and did it themselves while preserving the valuable objective data. They created their own hope in a seemingly hopeless situation. This is the ultimate expression of DIY Medicine, done properly and openly. Any other method is a waste of time, money, and health.

There is actually much more opportunity than just experiments with speculative alternative medicine. Hope exists for the approximately 60% of living PALS who don't qualify for clinical trials. That hope is the FDA Expanded Access Program (EAP). PALS should request EAPs for those investigational treatments which have passed the Phase 2 endpoint requirements of safety and suggested efficacy. Furthermore, they should support efforts to bring EAPs to the ALS Community. Living, even for the healthy, requires hope. We, the ALS Community, like everything else we have accomplished, must create our own hope by being pioneers and responsible citizen scientists.

Jumping Joan!

Only Two Days Until The Jump!

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Many Thanks To Those Who Have Donated!

Outta Tsai't!

I would like to give a little blog-love to my [Facebook] friend and a fantastic artist Francis Tsai. I came to know him through the ALS community and very soon became a fan of his art. When I learned he was selling prints online to help finance his care, I purchased a couple.

The first one I purchased was one he did prior to onset called "Trixie":

This was a gift to a friend who collects pin-ups. My next purchase was a much more recent one called "Horned", which sports Francis' motto "Adapt - Survive - Prevail":

The thing I really enjoy about "Horned" is that it completely (and very literally) illustrates Francis' motto. Not content with just fading away, he got a computer and some software and created it using only his eyes!

Francis truly exemplifies the willpower of PALS and the clever use of technology to overcome the physical limitations which come with advanced ALS. A person is the result of his/her mind, NOT the physical body. With a little willpower and some appropriate technology, PALS retain purpose and personal productivity and quality of life remains high.

Surf on over to Francis' DeviantArt and StorEnvy sites (linked in the images above) and check out his art. While you're there, purchase a couple of prints. The money goes to a worthy cause and they make great gifts!

PSAwesome

On Monday of last week, this excellent PSA was released by Team Gleason. It was shown on the big screens inside the Superdome but needs to be shown repeatedly on major network television (ie ABC/CBS/NBC). Please watch, share with friends, and send to your local network television stations. This is the kind of message that needs to get in front of the eyeballs of America. This is the celebrity action we have been asking for. Now let's do our part in getting it out there.

Wide Open

Tonight I found a double-helping of tasty news: "Regulatory T-lymphocytes mediate amyotrophic lateral sclerosis progression and survival" (PDF). So what's the big deal? Let me explain in two parts - the scientific then the soapbox.

Residentiality

Last night (at time of writing) I was treated to a personal guided tour of the Steve Saling ALS Residence in Chelsea, MA. My tour guide, via laptop webcam, was my friend Lisa Jones-Wyhlidko, the dynamo who does such excellent volunteer work for ALS Guardian Angels. She dialed me up using Google Hangout (up to 9 people in a group teleconference - a really wonderful free tool!) and said she was going to walk me around and show off the Residence.

Rescuebook

Technology is extraordinary. The level of communication made possible today by technology is unprecedented. This ability is also available for people with extreme disability (I wrote this purely with eye movement to distribute to the world...).

Response-able

I was recently alerted to a blog called Science-Based Medicine which had a post that was rather critical of me. The post was written by David Gorski, a managing editor of Science-Based Medicine. If you read the post, you can probably understand why I took a little umbrage to Dr. Gorski's characterization of my efforts. Below is my response to him, shared here for my readers' convenience.

Thomas Ohlson - Guest Blog

I would like to introduce to my readers my friend Tom Ohlson. He was diagnosed the same year I was and we are both "venterloquists". Although the circumstances suck, I am glad to have met him and am excited to present the following as a guest-blog entry. I feel exactly the same way.
Last week, on the 4th of July, scientists announced they may have discovered the Higgs boson. Frankly, I think if it were not a holiday and if there was nothing else newsworthy taking place, this announcement would have still have received little notice despite the significance of this discovery. This is unfortunate for a myriad of reasons, not the least of which is how American scientific curiosity has been replaced by a need for superficial sensationalism. Dont take my word for it--just look at the amount of major network news airtime devoted to the Higgs boson announcement vs. the Tom Cruise/Katie Holmes divorce announcement. Still, the discovery of the Higgs boson sounded a clarion call across the planet--great discoveries are still out there to be made and with them, comes great hope.

Letter From The Void

This letter was written in 2010 by another PALS who has since passed. I didn't always agree with him about certain things, but on this we most definitely do: ALSA National is letting us down. They have a nonexistent communication campaign unless it is to beg money from PALS (people already under severe financial stress). They have a basic research program that receives a small portion of the budget and no translational program (to move prospective drugs from the lab to the patient). They purport to provide equipment and services yet quietly refer people to other organizations because they "just don't do that". PALS may have good experience with their local Chapter (the OT in mine is an absolute superwoman) but there is no consistency between each Chapter.

This letter was written in 2010 and is unfortunately still true. ALSA is failing us.

Ms. Jane Gilbert,
I am writing to you as a 48 year old former airline pilot and victim of ALS, now in my fourth year. The purpose of this communication is to convey my terrible disappointment with the performance of the ALS Association at the national level. In my view, ALSA national is not putting the best interest of the patient community first. The game of baseball provides an excellent visual model of the awareness, advocacy, and research dynamics. Awareness is first base, advocacy is second base, research is third base, and a TRULY effective treatment resides on home base. Sadly, although the game has been playing for decades, the patient community has yet to reach first base. We have no unified national voice and no public awareness program. ALSA seems content to send e-mails to the patient community encouraging the purchase of cheap Chinese bracelets and have this serve as a national awareness program, which it clearly is not. The bedrock of an effective national awareness program is a series of public service announcements airing consistently on national networks. Anything less is a waste of time and resources. Here is what I can see during a typical day of television viewing. See if you can discover a pattern. Quite often on ABC at 6:45pm, I see an excellent PSA from the Alzheimer's Association, nothing from ALSA. I see KFC commercials for the "pink bucket" of chicken to support breast cancer initiatives, nothing from ALSA. I see PSAs for the breast cancer walk in DC on May 9th, nothing from ALSA. I see the PSA for the MS walk,nothing from ALSA. I see a PSA for the Epilepsy walk, nothing from ALSA. Earlier this year I saw yogurt commercials highlighting the "pink cap" for breast cancer, nothing from ALSA. Do you see the clear pattern that quickly emerges, Ms. Gilbert? Is this disservice to the patient community something to be proud of? ALS continues to be one of the best kept secrets in America because our national organization stubbornly refuses to initiate a consistent program of FREE public service announcements. Can you explain why ALSA refuses to place PSAs on national television? ALS Canada sets a fine example with their public awareness program, that includes an excellent PSA depicting all the phases of ALS in just a few seconds. After their PSA aired for a while, ALS Canada was pleased to notice a large increase in revenue. The PSA system is proven to increase awareness and donations, but it will not work if ALSA refuses to use it at the national level. Considering the bleak prognosis of the patient group, we need the loudest, most radical national organization to push progressive change. Anything less is a disservice to the ALS community. Because there is no national awareness program, and we haven't reached first base, advocacy is suffering on second base. An effective advocacy program depends upon an effective public awareness program. The public must know the details of ALS in order to support our cause. Likewise for those who control the federal research funds. A new phrase has been circulating on ALS blogs and forums. Anemic Advocacy. The sole use of this new phrase is to describe the advocacy of ALSA at the national level. Last year, we went to the Hill with tin cans to beg for only 5 million dollars from the DOD. This year we are asked to again approach the Hill for only 15 million dollars. While other patient groups demand adequate funding, we are encouraged to move in and sweep up the crumbs. Do you realize that even in 2001, HIV research was supported by 4 billion federal dollars? This year, the Alzheimer's Association is demanding 2 billion dollars. ALSA acknowledges that 95% of ALS research projects will go unfunded. This would not be the case if ALSA demanded real money instead of pocket change. This year, I will spend my time at the Missing Parts display. I will not carry the can to beg for table scraps. I will however, be willing to climb the Hill to demand not less than 250 million dollars in federal research funding. Swift access to investigational new drugs was a listed legislative priority in 2005 and 2006. Now that important priority is gone, and we still cannot access new drugs. When I asked ALSA for help with obtaining Iplex last summer, there was no interest. Why?I realize that ALSA may not be able to correct the many deficiencies in the research community, so I'll not dwell long on the third base of the model. Increased funding will help, as will increased communication between all research efforts. A major victory would be achieved if the conventional clinical trial structure were overhauled to reflect the reality of a fast moving condition such as ALS. The process must be simplified and streamlined. When patients don't live long enough to complete a trial, something is wrong. Just a few more concerns left. I know that a letter was sent to ALSA national some weeks ago asking that all organizations involved in the fight against ALS be welcomed to present at Advocacy Days. The request was denied. As a result, other fine organizations are forced to use the lobby or other hotels. Why is ALSA national so hostile to other organizations that just want to help? We need a unified effort, not political turf wars. What is the issue with signs this year? Last year, my daughter and I carried signs to increase ALS awareness and inform the public of our plight. The signs were very effective and well received at the conference, among the public, and on the Hill. Without signs, you can only bring the message to people next to you, if you still have a voice. You may know that many ALS patients lose their voice, therefor signs are the only means of personal expression and communication. With a sign, I can reach every person within 50' of my chair. I don't appreciate being lied to. ALSA seeks to prohibit free speech citing existing regulations prohibiting signs on the hotel property. Quick communication with the JW Marriott reveals that there is no regulation against signs. The element of trust has been damaged. I will once again bring my signs to communicate with the people. I do not wish to cause a disruption and I ask that ALSA not instigate a confrontation by attempting to take my voice away. I notice that the schedule is open on Sunday until 2 pm. Why are our veterans not being honored with a wreath this year?This is a public letter published on ALS forums. I challenge you to take the stage on Monday morning. Many within the ALS patient community will be interested in what you have to say.

The Fix-Up

To communicate (and do other things like write this blog) I use a computer set up with a special infrared camera and software which allows me to control the computer with my eye. The hardware platform this system runs on is a very nice little tablet PC from TabletKiosk. I chose the ERICA system from ERT specifically because it was based on this tablet which, even 4 years later, is way more powerful than all other competitors I know save one (and the new i500T easily matches that). Being an Information Technology professional I knew that I would be doing quite a bit more than just typing and talking, and would require the computing power and features of the Sahara Slate PC.

After years of heavy, daily, use, the system started having trouble with the sliding power switch. Sometimes the power light would come on but the system would make no noise and the screen would remain blank (it would fail to POST, for my fellow geeks). My assistant would have to hold the power switch for 5 seconds to turn the machine off and then try again. This frequently resulted in a total hang which required pulling the power cable and battery. Because the machine was mounted and had a docking cradle attached, this required some disassembly to get at the battery. Needless to say, as this problem became more frequent I became more worried that each procedure would result in a fried computer.

I looked up support on the TabletKiosk site and saw that they had a nice little online Forum for questions and user support. I posted a message and also emailed tech support in the hope they would answer (mind you this system is over 3 years old). After some anonymous queries back to me for more information I was contacted by the Director of CorpComm who helped me set up a process by which they shipped me a loaner identical to my system, I popped my hard disk in the loaner, shipped my system back to them for evaluation and repair, and then the reverse. This way I was able to keep my heavily-customized work environment during the couple of weeks required to complete the process.

The problem was with the motherboard, which was replaced. I have my system back and it's as good as new. These TabletKiosk PCs are nice and solid with a great list of features. I would recommend these to all my friends who want a reliable and powerful tablet computer that is Linux-ready (hint hint). TabletKiosk was extremely courteous and supportive and got me through what could have been a total disaster in my life.

I would like to thank by name John Kwan for his patient support and Lisa Herbert for getting the ball rolling and overseeing the process. It's not often that CorpComm meddles with TechSupport without tactical nukes being deployed... I would also like to thank the entire TabletKiosk team for making this able to happen. I very much appreciate their products and support

Guest: Persevering On NP001

A few days ago my friend, who goes by the handle Persevering on the TDI Forum, posted an evaluation of the PALS who have been self-reporting their experience with the Neuraltus Phase 2 trial of NP001 (which I have discussed here in the past). While the data looks exciting, I must caution that this isn't official data and makes some assumptions which, if wrong, could totally invalidate the evaluation. However, I have enough faith in Persevering to bring this to your attention. For those who don't have Patients Like Me accounts, I reproduce the graphs here.

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I have analyzed the NP001 phase 2 data from PLM to date.

I am aware of 37 PLM members who have participated in the trial and 34 who have entered sufficient data to track progress. This is roughly 1/3 of the listed full trial enrollment, and offers a great sample to predict actual trial results. The trial consists of 6 infusion cycles over 21 weeks (147 days), followed by 4 follow-up visits adding 16 more weeks. 13 have completed dosing. 11 will complete within 4 weeks, and all within 8 weeks.

In my thinking, since each infusion cycle is 4 weeks total, the first non-dosing follow up at week 25 (175 days) ends the dosing phase, and I have chosen to review data to day 175 in terms of FRS change. The variable of interest is FRS slope, and is very commonly used to evalauate efficacy for ALS clinical trials. For example, it was used in the recent report of Dexpramipexole phase 2 data, and was used for the official Lithium clinical trials in the US.

In my opinion it is possible to review reports of side effects for commonality to approximate those getting drug (either dose) versus placebo. I do not believe it is 100% accurate, and I also expect those getting a higher dose to have more or greater side effects, but it is not entirely possible to segregate the drug groups (high vs. low). Some may not be prone to side effects on drug and others could experience "nocebo" effects, so again this is not a true substitute for unblinding, which should occur later and allow a timely re-analysis of PLM data.

With that assumption/disclaimer, the summary statistics are:
(Green is improved FRS score, yellow is stable FRS down to -0.49/mo, and red is loss of FRS)

With side effects:

• n = 20
• Mean ALSFRS-r slope: 0.00
• Standard Deviation ALSFRS-r slope: 1.24

Without side effects:

• n = 14
• Mean ALSFRS-r slope: -1.01
• Standard Deviation ALSFRS-r slope: 0.68

Comparison: 100.4% mean improvement

2-tailed t-test p-value for difference = 0.0093

The most exciting outcome to me is that the difference in progression rate is very statistically significant (p<0.05), even with only 34 data points! This would be unprecedented for a phase 2 ALS clinical trial. For example, the recent exciting report regarding Dexpramipexole, with a 31% mean improvement versus placebo in the first 12 weeks had a p-value ~ 0.20, a value 4 times higher than acceptable to conclude drug is better than placebo, by convention (based on a sample size of 53).

There is rumor of an official NP001 trial efficacy review soon, based on all data available on January 24, 2012. Let's hope for statistical significance there as well, and potentially FDA accelerated approval, as occurs for cancer and HIV drugs.
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Thanks to Persevering for the work and for the guest-blog!

Nothing Vented Nothing Gained

I have long been an advocate for PALS going on a vent. Many opt out for various reasons, one of which is, surprisingly, discouragement from medical professionals. Horror stories of cost and the difficulty of home care are common. I beg to differ with that. Cost can indeed be an issue but with creative financing and the possibility of obtaining long-term care insurance before formal diagnosis, cost can be managed. In terms of home care, with a few simple rules adhered to, the risks of complications are minimal. Up until now I had only my own experience to use as proof of my contrarian view. It turns out I was correct all along. In a study of over 100 PALS 78 were recommended for tracheotomy. 38 underwent the procedure. Of those, the one-year survival rate was approximately 80% (the same as lung transplant) and only one died from respiratory causes. As the study noted: "Nowadays, starting [home venting] should no longer necessarily be considered as the beginning of the end for these patients. When the appropriate medical resources are in place and the patients wish to continue living, the old mentality of focusing only on palliative care which is still common in the management of this disease must make way for high technology and compassionate care." Vents today are about the size of a grammar school student's backpack and very quiet. Assisted Communication Computers are covered by insurance and Medicare and are very easily converted to general-use Internet-capable computer systems. Web-based social media platforms give unprecedented communication and social access to today's PALS. I have cheated The Reaper for 4 years now and others have for longer. In my view the old bastard can piss off until I am good and ready to go. My quality of life is what I make of it. Technology is my friend and has been for most of my life. As the esteemed Steve Saling says, "Until medicine arrives, technology is the cure." I believe this and urge all PALS to use technology to win the battle against ALS until medicine provides the final victory.

Another Victory

This is why we do it. Olya in the Ukraine needed a biPAP which she couldn't possibly afford. She contacted ALS Guardian Angels. I chat with the ALSGA coordinator quite frequently, heard the story, and donated my old biPAP. ALSGA shipped it to Poland and Olya's friends got it to her from there. Another PALS given more time alive by cooperation and action within the global PALS family. Although I appear in this story, it is not about me: It is about how we as PALS can change our own lives and the lives of each other. Without the new communications technologies now available (and the ability to use them) this could not have happened. The following is an email trail following receipt of the biPAP and a technical issue resolved. Some of the discussions took place over real-time chat and so aren't shown here. Total time from request to receipt and use was less than a month. -------------------------------------------------------------------------- From: Olya@.ru To: @.com Subject: I want to say thank you Date: Thu, 31 Mar 2011 00:19:27 +0400 Hello, Lisa! I can't wait to share my happiness with you. Today I've used the bipap for an hour or so for the first time and I felt excellent. Much better than without it. I learned how to do settings. I find my mask to be comfortable too. I feel deep relief now. I'm not scared any more not being able to breath normally and sleepless nights are the past. I've attached a picture of me while bipap therapy. Now I'm thinking back and understand that is would not be possible without ALS GuardianAngels, Stu and your priceless help. There were obstacles to ship the bipap and receive it, but you were so patient and sympathetic to me and to all this process. I sometimes can't believe it's true. When I tell people, that an American organisation helped me with the bipap and tell them this story,they say: "It's something unbeliveble, it's really hard to believe that miracles do happen". You can't imagine how much your help means for me and my family. I'm writing this and understand that I can't find right words to express how grateful I am.I also want to tell Eric (the donar) that his donation means '"surviving" for one more PALS (for me). That this is more than a gift! That I will always be grateful to him and never forget it. I want to cry out THANK YOU FOR EVERYTHING YOU ARE DOING FOR PALS! IT'S PRICELESS! Happy Olya 29.03.2011, 17:18, "ALS GuardianAngels" <@.com>:YAY, I am so relieved! Here is the companies contact information: Respironics Inc - 6 reviews - Place page www.respironics.com - 1001 Murry Ridge Drive, Murrysville, PA - (724) 387-5200 From: olya@.ru To: @.com Subject: Re: Olya: Mission accomplished! Date: Tue, 29 Mar 2011 15:09:30 +0400 Hello Lisa, It was voltage issue (the user guide info was right). My husband bought another adapter and the bipap works with the new one. Actually, at first we used an adapter too (an American one, as we have American product and it does with the device), but the bipap didn't work with it, but Ukrainian adapter is good.Thank you, Lisa, for your help, anyway. I was really worried. But I still need the contact of a provider in case something goes wrong in future.Model ð 1003986PCA1SN:3074661My phone number +38 095 700-68-67 29.03.2011, 02:25, "ALS GuardianAngels" <@.com>;:Also, please send me the model number and serial number...any other information would be great. A detailed reply about what is happening will also be helpful. Send me your phone number again as well. From: @.com To: olya@.ru Subject: RE: Olya: Mission accomplished! Date: Mon, 28 Mar 2011 18:23:01 -0400 For now, bring it in to your doctor at your appointment...they may have some advice. I'm hoping it's not a voltage issue between US and Ukraine products...we looked into that and we were certain it wouldn't be an issue. I can look for contact info, I already called them to see where the device was originally made (needed that for Customs). I will call them tomorrow as they are closed already today. From: olya@.ru To: @.com Subject: Re: Olya: Mission accomplished! Date: Tue, 29 Mar 2011 01:59:47 +0400 Picture is attached. This is what I see on the screen, when trying start the bipap. 29.03.2011, 01:07, "ALS GuardianAngels" <@.com>;:Olya, here is the user guide: http://global.respironics.com/UserGuides/UserGuideBiPAPSynchrony.pdf Let me know if this helps or not. Otherwise, I can definitely ask the Donor if he has any suggestions. From: olya@.ru To: @.com Subject: Re: Olya: Mission accomplished! Date: Tue, 29 Mar 2011 00:51:09 +0400 Hello Lisa, We have just tried to start the bipap and failed. It does turn on, but in several seconds long alarm sound and red solid and yewllow solid turn on while system self test. I think we should adress the provider, but we don't have one. Could you advice what to do? 28.03.2011, 17:58, "ALS GuardianAngels" <@.com>;:I just received this wonderful update form Olya! Also, since Olya wished to thank the donor I included him on this message. Olya, his name is Eric Valor...and he's a wonderful man and PALS from Santa Cruz, California. Thank you all, and Olya I look forward to more updates on how you are doing! - LisaFrom: olya@.ru To: @.com Subject: Re: Need help to live with ALS Date: Mon, 28 Mar 2011 16:53:01 +0400 Hello, Lisa! I have news. I've just received the bipap and the mask. I didn't try it yet. I'm going to see a doctor tomorrow and she should do all the settings. But I'm very excited I have the bipap. I will do my best to get accustomed to it. There is a nice surprise. When I opened the box, I found a humidifier there.I can't express how grateful I am to you and Stu and the donor and to all the people who helped me to get it and of course to God, who arranged my meeting ALS GuardianAngels. I'd love to thank the donor who agreed to donate it to me. I hope you can deliver my thanks to him. I am really very very excited. I can't believe everything is done.I will write you how I am doing with the bipap. Olya