ALS Advocacy

ALS Advocacy
Lou Gehrig's Disease - Motor Neuron Disease - Amyotrophic Lateral Sclerosis
Thought it had been cured by now? Still no known cause. Still no cure. Still quickly fatal. Still outrageous.

Sunday, September 27, 2015

ALS, American Airlines,, La-Z-Boy, and YOU

Yesterday I had the privilege of delivering an Ignite! talk at Stanford University's MedicineX.  I appreciate the opportunity to present a message about ALS to so many outstanding people whose mission is to rebel and improve medicine.  Thank you, #medx .

Information.  It’s the food we use to improve everything we do.  It’s the feast that drives innovation, yet we waste so much.
Food deserts are a big problem in our urban areas.  I think that information deserts are a big problem in healthcare.  Do we find ourselves munching on what’s convenient rather than what’s really good for us?

 People dealing with ALS have a bumper crop of information that is often left to wilt on the vine.  That's an unacceptable waste, especially with a fatal mystery disease.
You see, the ice didn’t cure ALS.  There is still no known cause.  There is no effective treatment.  It is a difficult, steep, downhill path to death.
Yet everyone in this room, regardless of what your role is in medicine, can benefit from information from those dealing with ALS – you, physicians; you, drug developers; you, entrepreneurs; you, smart students.  Let’s talk a little about harvesting that information.

Before Mom died from ALS, she liked to take a trip every now and then.  American Airlines retained more information about her travel history than medical science retained about her case of ALS.  That’s outrageous.  All the clues that her life and medical history harbored were buried with her.  We’ll never connect the dots if we don’t start collecting the dots in an orderly and complete manner.  Somebody, call American Airlines, please!

Shopping for shoes is challenging for me, but not nearly as challenging as shopping for an ALS clinical trial.  Often when someone is diagnosed, a family member is put in charge of Dr. Google to go find something. 

You hope that “something” is a clinical trial.  It advances the science and is a legitimate Hail Mary for someone with ALS, but trials are not easy to find.  You have to sift through enrolling interventional trials to try to find the most “promising” science.  And you get emails out of the blue.  It’s confusing.  It’s time consuming.
And speaking of time, most ALS trials have a 24-month eligibility window from onset of symptoms.  There is typically a 12-month delay-to-diagnosis with this disease.  See a problem with time, here?
Last week I got an email from, Zappo’s outlet store – “The perfect shoes for you, and on sale!”  I took the bait.  I clicked on the message.  Up popped a cute pair of shoes that looked like they would work for me.  I’ve bought a total of three pairs of shoes in my entire life from, and they were able to make a pretty good match for me, yet clinical trial matching is stuck in the 1980s.  Somebody, call, please!

Yesterday we talked a lot about precision medicine.  I think we need to talk about accurate medicine, too – the right intervention at the right place at the right time.  So often with ALS it looks more like this… We constantly throw the ball five yards behind the receiver.  That does not help the patient.  It’s wasteful.  It’s expensive.

I have a wonderful old reading chair – a 50-year-old La-Z-Boy.  It is so comfortable.  Last winter it broke.  It was stuck in the upright and locked position.  I was heartbroken.  I called my local La-Z-Boy store and a fellow in the warehouse was able to diagnose the problem over the phone – a broken part.  Oh, no.  He said not to worry.  They would find one. I could pick it up after noon the next day.  Really?  Try breaking a part on a power wheel chair that is far more important than my reading chair.  You get a shrug and , “Four to six weeks, what can you do…” 
I’ll tell you what you can do.  You can and you must measure.  It’s about information.  You measure performance.  You set benchmarks.  You improve processes.  Somebody, call La-Z-Boy, please!
I have a challenge for you all and it doesn’t involve ice.  Please consider ALS to be a stress test for whatever it is you do in medicine.
You’ll never become a great skier if you stay on the bunny slopes, and trust me, ALS is no bunny slope.  It’s a difficult disease.  It’s a demanding disease.  It’s often a very fast disease.
If you can learn from those dealing with ALS, you will improve.  You will innovate.  And I guarantee you will be better for every patient you ever serve.

Copyright 2015 @ALSadvocacy All rights reserved. 

Saturday, September 19, 2015

Terms You Never Hear In The Same Sentence -- Nimble, Information, ALS

Several years ago, a local investigative reporter did a segment on lead in dishes and children's health. Our Board of Health offered free testing of dinnerware.  Lead is never good.

I took one of my everyday dishes to the testing site and brought along one of Mom's dishes that she and our family used every day for half a century.  Hers was Franciscanware, a high-quality, everyday china that millions of housewives of the 1950s treasured for their families.  The patterns each family had were expressions of mothers' favorite colors and themes.

When I had the china tested, I expected that my everyday china that I had bought on sale at Marshall's would test high and I would toss it.  Lead is never good.

I also expected that the Franciscanware would be deemed safe.  What a surprise I got.  Yes, my inexpensive everyday china tested high, but the Franciscanware tested even higher.  Yikes.  Lead is never good, and if you've ever seen ALS, you have no desire to take any potential chances with any substance that can possibly mess with your neurons.

On a recent webinar on possible causes of ALS, I asked if anyone had ever studied the lead content of   the dishes that people with ALS had used.  I didn't get a direct reply to my question.  The scientist just said, "Lead is never good."

ALS is a fatal mystery disease, yet we have no nimble systems for gathering and reporting on possible risk factors or causative factors.  The studies take years and the information-gathering nets are not cast widely (quite possible because the studies take years and the disease often kills people quickly).

We need nimble.  We need complete and organized information.  This is not rocket science.  We need ways to gather and harvest information quickly.  What if there are some simple preventive measures we can take in our everyday lives?  This is a matter of life and death.

Lead is never good.  In the meantime, I've tossed all the dishes.  I've seen ALS and it is never good, either.

Sunday, August 23, 2015

Is It Wrong To Yell "Fire Extinguisher..." a crowded, burning theatre where the doors are all locked?

Of course not if you have a fire extinguisher in your hands and are trying to clear a path to help.

It would be very wrong if you have a great blueprint for an awesome  extinguisher (that you consider to be a "breakthrough" in snuffing fires)  and a successful experiment and a patent application but have yet to go through rigorous testing, certification, approvals, pilot production, or production.  You would set a really cruel expectation amidst a lot of people facing death.

Last week was an interesting one in the fight against ALS.  We had already seen the news published August 7 about TDP-43 in Science

That was certainly another good scientific step forward.

In a tenuous attempt to link the scientific good news to last August's ALS Ice Bucket Challenge, we started getting crafty statements.   What better way to encourage donations this year than to associate it with a recent advance in understanding ALS?

Media coverage was being cultivated, and this makes a feel-good story about the marvelous, fun phenomenon of August, 2014.  It makes a wonderful feel-good story.

Then there was the Reddit AMA exchange with one of the paper's authors followed by some national interviews.  A tie of the #ALSicebucketchallenge to this project was emphasized.  Wow.  We did that with the ice, eh?  A young scientist almost seemed giddy with enthusiasm about the significance of his discovery.  Double-wow.  And this was emanating from one of the finest academic medical institutions in the nation, Johns Hopkins.

As Answer ALS aptly described in a statement on Facebook, "The headline seen this evening had the phrase 'A Cure for ALS Could Be Coming Soon.'  As the last few days have gone on, the headlines seemed to create themselves... "

And for families craving optimistic sound-bites as they deal with ALS, were they ever getting the optimistic sound-bites, right from the scientist's mouth.

And the ecstatic news went on and on.  Mission accomplished?

Perspective, anyone?

  • When did this work start?
  • How much did the project cost and exactly who supplied what funding? 
  • What are the next steps?
  • How much money is needed for the next steps?
  • What is the most optimistic timeline for the next steps?
  • What are the barriers (scientific or regulatory) to bringing this finding to a therapy?

That clarity and perspective will help us all to understand not only the significance of the findings but also what we all need to do to help bring those headlines to reality.  

Maybe we need to talk about patient-centric p.r. and fundraising.  A respected medical institution needs to celebrate its achievements and raise funds with respect for the patients and caregivers and loved ones who are trapped in a burning theatre.  They just heard "fire extinguisher" on the national news last week.

Wednesday, August 19, 2015

Say What?

It started on August 13 with a tweet from an ALSA executive, "#ALSIceBucketChallenge donations have led to a significant ALS research discovery! "

Wow.  Impressive.  Holy cow.  That was fast.  Say what?

The press release was very carefully couched and didn't quite mesh with the cause-and-effect excitement of the tweet, but the seed was planted.

Then it continued with organizational tweets with wording that matched exactly.

Amazing. Remarkable. Cool.  Say what?

Then yesterday there was the ALSA mass emailing -- Subject line: "This is amazing news!"

Yes, amazing.  Fabulous. Incredible.  Say what?

The cause-and-effect implication is clear.  IBC donations to ALSA led to this discovery?  That's fast science.  How refreshing.  Say what?

We didn't get a good list of  #ALSicebucketchallenge checks written to researchers last year. We saw numbers related to committed funds.  In these lists of funded research, I don't see this project listed in the 2014 file but Dr. Wong is listed as a $160,000 grant recipient in 2015. 

The full research paper on this "significant #ALS research discovery" sits behind a paywall.  My curiosity won last night.  I bought access. Let's see how this breakthrough was funded with IBC funds, was discovered, was written up, was reviewed, and was submitted to a journal between August. 2014, and March, 2015.  That's cool fast science.  Say what?

Acknowledgements at the end of the paper included that the project was funded in part by
  • The Robert Packard Center for ALS Research
  • Muscular Dystrophy Association
  • The Amyotrophic Lateral Sclerosis Association
  • Target ALS
  • The Johns Hopkins University Neuropathology Pelda Fund
  • The Johns Hopkins University Alzheimer's Research Center (NIH P50AG05146)
  • The Samuel I. Newhouse Foundation

Unfortunately we don't know how many dollars were involved or how much each agency contributed or the dates of the grants.

The paper itself is complicated and involved experiments and evaluations on mice followed by more work on deceased PALS' brains.  There isn't a timeline but it would have taken a miraculous change in the ALS research paradigm for any substantial amount of this discovery work to have been carried out in Q4 of 2014.  I would be amazed if the illustrations alone could have been made and approved in six months, let alone all of the underlying work.

And there was even mention in the paper of a patent application filed by two of the authors. 

So the "Say what?" response keeps going off when we read the tweets and the emails.  How can this be?  Is it a deceitful way to make people feel good about their last year's IBC generosity so they'll do it again?  Or was there really a scientific funding-to-discovery-to-journal miracle in six months?

People with ALS and their caregivers have been pressing hard for the FDA to speed up approvals. They get pushback from organizations including ALSA that good science takes a long time.  Then we get self-serving fundraising messages that our donations led to a "breakthrough" in under six months in some remarkable fast science.  Say what?

People are dying.  They deserve some clarity.

If my "Say what?" reaction was out of line, I'm all ears.

Monday, August 10, 2015

"Do You Know What The Worst Part Is?"


That's a movement that originated with @speed4sarah.  You can read up on it on her blog

I decided to give it a try.  I would try to give up something that ALS takes from people.  It would raise some awareness.  It would raise some funds.

One thing that really stuck with me when Mom had ALS is that we take so much for granted -- taking a sip of water without choking, working a door lock, talking to one another.  There was such a spectrum of things that I could "give up" for #whatwouldyougive.

Mom still had good grip strength during her ALS but it was terribly difficult for her to lose the dexterity in her fingers.  The inability to work a lamp switch or button a button was so frustrating for her.  More on that later.

I set my #whatwouldyougive bar very low.  I didn't want to fail.  My left hand in a ski mitten  for a day shouldn't be that tough.  I'm right-handed.  I picked a weekend day when I wouldn't have to do my day job. I didn't want to have to ask anyone for help, so I kept it simple.  One free hand would work.  I would be safe driving.  The bar was so low that I felt like a sissy.

Enter Sunday morning.  I put the mitten on first thing.  Immediately I realized I couldn't scratch the dog like she expects every morning.  Not a big deal, right?  On to fix my toast and tea.  It wasn't pretty when I realized that I could not slice my toast the way I've sliced my toast since I was six years old and learned to make my own toast.  Thirty minutes into my experiment, I said, "Boy, I'll be glad when this day is over."  Ninety minutes in, I was totally frustrated.  I wanted my old life back where I could slice my toast my way.

I've broken my right wrist twice in my life and I was never this frustrated (there's that word again).  I decided that immobilization feels good when something hurts and there is healing going on.  That's not how this was.  It was just exasperating.  I couldn't clean my eyeglasses.  I couldn't floss.  My right arm itched.  It was incredibly frustrating.

For my sanity, I decided to try some distraction and went to the grocery store.  It went well until I needed a produce bag.  Ah, plastic bags were my bane all day, at the store, in the wastebasket, on the dog walk.

By late morning I was really hungry and had no desire to frustrate myself more by cooking.  I stopped in a local restaurant that was still serving breakfast.  It was one of the best experiences of the day.  We talked about the mitten and the hashtag and they fixed me a good breakfast that required no knife dexterity.

I had been making a list of the day's challenges and finally stopped listing them.  We take so much for granted.

The first time Mom asked me to help her button her blouse, she asked, "Do you know what the worst part is?"

No, I didn't.

"When I've lost the ability to do something, I know I'll never do it again."

She had buttoned her last button.

At the end of my experiment I took off my mitten.  My life goes on.  My toast is right this morning.  And how many mothers with ALS buttoned their last buttons yesterday?


Please set a challenge for yourself and try it.  Low bars are fine.  Trust me, it's not easy.  And then support

Or give directly to @speed4sarah 's research cause at 
Or give to that supplies technology to those with ALS to help compensate for those abilities that ALS steals.
Or do all of the above.  After all, we take so much for granted.

Wednesday, August 5, 2015

Let Me In, Whee-Ooh

"Let Me In"
The Sensations - 1962
Let me in whee-ooh (whee-ooh, whee-ooh, hoop-whee-ooh) 
(Whee-ooh, whee-ooh, hoo-ooh-oop-whee-ooh, whee-ooh) 

I can see the dancin' (let me in) 
The silhouettes on the shade 
I hear the music (music), all the lovers on parade 
Open up (let me in), I wanna come in again 
I thought you were my friend 

The big ALS symposium is coming up in December.  Already we're seeing news of abstracts accepted and discoveries that will be presented.

The registration fee of approximately $600 goes up even more after August 19.

There are people with ALS and their loved ones who are interested in good science.  They spend countless hours searching.  A gentleman I knew with ALS attended the symposium in 2010 and found an interesting drug candidate and enrolled in the clinical trial as soon as it was available.

Why would we not want people with ALS or their loved ones at such a symposium?

Why would there be so many barriers between PALS and this festival of information about good science?

The fee without any consideration for people with ALS and caregivers is one of the big barriers.

The lack of welcoming information for those who aren't insiders is another.

The spirit and letter of the Patients Included movement needs to be in the fabric of every ALS meeting, especially the premier scientific symposium.  It's past time for this meeting to be physically and virtually accessible to every PALS or loved one who is interested.

Thursday, July 30, 2015

Of the PALS, By the PALS, For the PALS



It's happening thanks to some formidable people with ALS and caregivers.  They aren't waiting for a system that doesn't understand urgency.

Here is a posting from a gentleman with ALS on the forum (it requires registration to view) at
Rich Casey, the CEO of Neuraltus, mentioned that ALSA is considering funding an Expanded Access (Compassionate Use) program for NP001, in addition to its $1.5M grant for a new clinical trial. As you know, Phase II clinical trial of NP001 yielded promising results in 2012, though falling short of its effectiveness goals. However, post hoc analysis identified "responder" biomarkers. Neuraltus has been trying to secure more clinical-trial funding ever since. Now ALSA expressed interest in underwriting a Compassionate Use program for NP001, along with the trial. Neuraltus believes there is an immense interest in the ALS community for this idea, but would like to have concrete evidence. Having a ready list of potential participants would help this cause, demonstrating the unmet need to ALSA as the sponsor. If you are interested, send a letter to Neuraltus requesting compassionate use access to NP001. This would strengthen Neuraltus's hand in dealing with the FDA as well as ALSA. We also should emphasize that the drug should not be withdrawn from those it helps, to prevent " crashes", like those experienced by Persevering and others during the wash-out period of the 2012 trial.

To: Rich Casey
Below is a  bare-bones sample letter to sign and send, but it would be good include your personal information and why you need NP001. 
Thank you. 

Dear Mr. Rich Casey,
As a person with ALS I want to join the Compassionate Use program for NP001. I am aware that the upcoming clinical trial would have only a limited enrollment. A large Expanded Access arm would benefit ALS research and help PALS. It is also important that long-term access to the drug should be ensured for those participants that benefit from it. Sincerely,
Xxxxxxxx Yyyyyyyyyyy

There are a number of threads on the forum at that discuss NP001.  I urge any PALS, CALS interested to read them.  It definitely did something in some PALS in the Phase 2 trial.  Some also crashed terribly when the drug was taken away.

Here is an article from the WSJ regarding one of the PALS who was in the last Phase 2 trial in 2012:

And finally, here is a powerful letter that one of the Phase 2 volunteers just wrote to Mr. Casey:

Dear Mr. Rich Casey,
As a person with ALS I want to join the Compassionate Use program for NP001. I was in the NP001 Phase II trial and received the high dose. NP001 stopped my ALS dead in it's tracks during the time I was on it. I know first hand that NP001 is a safe and effective treatment for ALS patients. I am aware that the upcoming clinical trial would have only a limited enrollment. A large Expanded Access arm would benefit ALS research and help PALS. It is also important that long-term access to the drug should be ensured for those participants that benefit from it. Thank you for the opportunity to provide NP001 to the broader ALS community, I know it will save many lives.
Kindest regards,
Certainly an expanded access program isn't ideal, but it is something.  This potential therapy for some PALS (elevated IL-18 was cited as being characteristic in responders) has sat on the shelf for almost three years while the drug developer has not been able to raise the capital needed for a Phase 3 trial.  The system is broken.  Why scientists have not been more curious about what was happening with this drug is beyond me.

People with ALS and their caregivers are taking matters into their own hands and trying to open up some options.  They are demanding and getting attention.

I encourage all PALS, CALS who are at all interested in trying to email Mr. Casey now at .  

Thursday, July 23, 2015

Urgency: People with ALS and the FDA

People with ALS and their caregivers understand urgency.

People who work for a large government agency simply don't.

It's time for the former to change the latter.

The people with ALS and caregivers at have issued an update and a call to action.  It is long but well worth reading below.  It will enlighten some and it will make us all think.  These are grassroots people with the ultimate skin in the game. They have studied.  They are thoughtful.  They are leading.  They have made tangible, reasonable proposals to the FDA.  They will also listen to you if you have different or better ideas.

Then please act.  A few messages to FDA officials won't make a difference.  A few hundred might.  A few thousand will.  Please contribute your thoughts directly to FDA employees who work in a bureaucracy that simply does not grasp urgency.

Then please ask others to act.  This is how we all can make a tangible difference.

Thank you.  It's urgent. The FDA needs to know that we're not going away.


Please read and share this important update! 
Hope Now for ALS update: Summary of July 6th call 
Dear Hope Now for ALS (HNFA) supporters, 
We apologize for the delayed update. We have been trying to schedule the next meeting so we could report that in this update. After our July 6 meeting, we submitted a detailed proposal to the FDA and requested a timely response, but it appears the FDA is stalling. They suddenly want to invite other “stakeholders” to our meeting. We believe this is a tactic to bring people and organizations into the discussion that will defend the status quo and to convert the role of actual PALS and CALS into a minority voice. With much regret, we need to report that after three meetings we see little evidence that the FDA is willing to be flexible with respect to clinical study designs and data analysis approaches that could accelerate the development and delivery of safe and effective medicines for ALS. WE WILL NOT ACCEPT THIS! 
Please write the FDA today and copy members of Congress and the media expressing your outrage that ALS is still not being treated with urgency. Demand that the FDA respond immediately to Hope Now for ALS (HNFA) in a substantive and meaningful way as they promised they would. State that you regard Hope Now for ALS as your representative for this process and that you expect the FDA to continue timely, direct discussions with HNFA on expedited and modernized development and approval pathways for ALS treatments – a 21st Century Approval Process! 
Please email Dr. Woodcock at the and copy the people below and your representatives and media contactsdruginfo@fda.hhs.govrichard.mosc 
Summary of the July 6th conference call 
Our third meeting with Janet Woodcock and her staff focused on finding common ground; specifically, balancing the need for faster, less costly, more conclusive trials and the FDA’s desire to keep ineffective treatments off the market. We were able to agree on FVC (change) as a primary endpoint, and ALSFRS (change) as a secondary endpoint. The ensuing discussion focused on topics fundamental to designing quick confirmatory studies that could lead to approvals for drugs/treatments that have demonstrated safety and preliminary evidence of efficacy in Phase 1 or 2 trials. Two principal topics that emerged from this discussion were (1) use of a patient-specific ALS progression predictive algorithm to construct a virtual and homogeneous placebo trial arm designed to reduce statistical noise in trials caused by the heterogeneity of ALS; and (2) understanding where and how the FDA can show some flexibility in the use of its statistical significance standard based on calculation of a p value as the standard for establishing “efficacy.” Achieving a p-value of < 0.05 in a trial where measuring a modest improvement in ALS progression is the primary endpoint necessarily increases trial size to substantiate positive outcome, adding time, cost and other complications that function as disincentives for companies to pursue approval of new medicines for ALS. However, by incorporating progression prediction models and patient-specific data, a 21st century approach to trial design, we would be more likely accurately measure the effect of the drug, improving the chances for recognizing of success when it occurs. We also advocated for the collection of secondary data in trials especially investigational biomarkers, and stratification of patients to better discern evidence of “efficacy” and to identify subsets of patients who benefit from a drug when efficacy is not seen in a majority of the patients. Unfortunately, as with our previous in-person meeting and our prior teleconference with FDA, we did not receive clear, actionable responses from FDA, and on some critical points of discussion, we encountered firm resistance to any form of new thinking in how drugs for ALS are developed and approved. 
Detailed Notes of the July 6th Conference Call 
On June 6, 2015, Hope Now for ALS held its third meeting with the FDA to discuss creation of an expedited development and approval pathway for new ALS treatments. We opened the meeting with some sad news, informing the FDA that a member of our leadership team, Dr. David Huntley (husband of Linda Clark – also on our leadership team) lost his battle with ALS on July 4th. We informed the FDA of his passing at Linda’s request to remind everyone that making and delivering progress for ALS is a matter of extreme urgency. FDA responded with an expression of sorrow and a statement that they understand and share the urgency felt by the patient community. 
Bob Hebron led the meeting for Hope Now for ALS (HNFA). The primary participants for FDA were Drs. Janet Woodcock and Ronald Farkas, although most of the FDA participants from the prior call also attended. 
HNFA introduced the concept of using a predictive algorithm to select patients for a study, and then to serve as a second control arm alongside an actual control arm with the objective of reducing the statistical noise caused variability in the rates and characteristics of progression among PALS. The predictive algorithm approach was then discussed in some detail, including input from experts developing a predictive algorithm for ALS using existing patient data. It was explained that the algorithm accurately predicts decline in ALSFRS and can be adapted to predict other measurement endpoints, such as FVC.HNFA then proposed that a clinical study designed to test for a slowing of progression could be conducted by using the predictive algorithm to select fast-progressing patients (termed “enrichment” by FDA) that could fill the study with “like” patients in terms of rate of progression. A positive effect on fast progressors might be seen more quickly (statistically), and in a smaller study population, than trying to discern the same effect in a population of mixed rate progressors. FDA indicated that enriching the study with fast progressors might be acceptable to them, and they expressed an openness to using the predictive algorithm for that purpose; however, they noted that if the study were populated only with fast progressors, the results might not be as generalizable to the larger ALS population as it would be if the study were run in a broader population of PALS (i.e., fast and slower progressing PALS).  
HNFA then proposed that the study could perhaps be stratified (meaning looking at subgroups within the population) to learn more from the study, and to try to further reduce the statistical noise generated by the variability in the progression rates and types of motor functions lost as the disease progresses, seen at the individual patient level. FDA responded that attempting to stratify a study prospectively would complicate study design, lengthen the time needed for enrollment and cause the study to have to be larger (i.e., FDA would be looking for a much larger, longer study with each subgroup large enough to have adequate statistical power if the sponsor intended to draw conclusions regarding drug effect based on any subgroup analysis). FDA then said that retrospective analysis could be conducted on the study results to try to understand what happened, but the implication was that retrospective analysis would likely not support an approval. 
HNFA then made the point that the patient community is looking for an agreement with FDA on smaller, smarter studies to keep the cost down and speed up the entire process. 
FDA’s response was entirely statistics-based and summarized below:• A study can be small if there is a huge treatment effect• A small study risks statistically missing a small treatment effect• FDA reported that some Breakthrough drugs approved based on early data didn’t show a large treatment effect in later confirmatory studies.• FDA advised that once an expected treatment effect is estimated (e.g., how much more slowly a drug might cause ALS to progress in the study population), cut it in half and design the study to be large enough to detect the smaller treatment effect to a level of statistical significance.FDA did not directly respond to our statement regarding an agreement on smaller, smarter studies. 
[Explanation – not from the FDA. What FDA actually said here is that they expect any entity trying to develop a new drug for ALS to do conduct the same large, time-consuming. randomized controlled studies today that the agency would have required 10, 20 or even 30 years ago. The FDA’s response is rooted in its long-standing its adherence to a purely statistical approach to designing studies and evaluating study results, and is based on the results of at least one, and preferably two, randomized controlled studies producing positive results at a measure of statistical significance, called a p-value, of 0.05 or less. Setting the p-value requirement at 0.05 or less means (in simplified terms) that the chance the results seen in the study happened because of chance (and not because of the drug) is 5 percent or less. FDA was explaining that an acceptable p-value can result from a large treatment effect in a small population of patients; however, to detect a small slowing of progression to a level of statistical significance acceptable to the FDA (p = 0.05 or less), a much larger, longer, more expensive study would need to be run. This convention, which has been relied on by FDA for decades as its standard for approving new drugs (since the 1960s), creates a reality in which getting a modestly effective drug approved by FDA takes much longer, costs much more and is much more uncertain for sponsors, than getting a highly effective drug approved. Given the current state of the medical science for ALS, all the drugs currently in the pipeline appear to have the potential for causing modest positive effects on disease progression and symptoms; thus, the FDA’s position on study size and statistical significance creates a financial and technical barrier to sponsors who might otherwise be interested in trying to navigate the agency’s development and approval process if a more creative and financially-feasible pathway was available. It also creates an obvious problem for the current and future generations of PALS and CALS who are faced with a drug development and approval process that makes approval of a new drug in a timeframe meaningful to them, all but impossible. HNFA is attempting to negotiate a more reasonable and productive development and approval path for ALS treatments with the FDA. So far, it appears that FDA has no interest in joining us in thinking outside the traditional statistical box.] 
HNFA raised the concept of using the predictive algorithm to analyze the study results as a second control arm (run alongside an actual control arm with patients receiving a placebo) that might be a better way to control a study because of the algorithm’s potential to reduce statistical noise associated with variability among patients and the accuracy/precision noise known to be associated with measures like the ALSFRS and FVC. FDA replied that they would not object to looking at its use as a control arm, and that the usefulness of the algorithm could be evaluated by comparing the control outcomes predicted by the algorithm with the outcomes from the actual control arm. FDA described use of the algorithm for this purpose as exploratory, and appeared to be disinclined to rely on anything learned from its use to interpret the study results. 
HNFA then asked: What is different about the input we are receiving from FDA today from what we would have heard 5, 10, 15 or even 20 years ago? FDA responded that the difference is they are talking to us about it – something they would not have done in the past. FDA did not offer any other explanation of differences between the advice they are offering us now versus what they would have advised in the past. HNFA then proposed that the study should include a cross-over provision (to the active drug) for patients randomized to the placebo control group, if after an appropriate period of following the patients in their respective groups (treatment and control), the drug appeared to be having a positive effect for some patients. FDA responded that they thought we were talking about a delayed start trial where some patients would start on a placebo, then be switched to the active drug. We responded that we were actually proposing a more traditional randomization to treatment or placebo at the start, with cross-over at the end of the monitoring period, and that if some of the patients who crossed over to the active drug then responded to treatment (for example by seeing their progression slowed), those responses should be considered favorable and could be compared to the predicted rate of progression using the algorithm. FDA did not provide a clear response to this concept but seemed to be discouraging it, and we raised the question regarding why FDA had never developed a way to consider patient responses observed after cross-over from the control to the treatment group as evidence supporting efficacy of the drug being tested? FDA responded that they were talking about these kinds of concepts at a high level but had not begun applying them at the study design and review level. 
HNFA expressed its growing frustration that we do not seem to be getting clear and actionable responses from FDA. In response FDA asked that we submit a list of things the FDA had expressed “openness” about so they could confirm or clarify their position.FDA reiterated its concerns about trying to use biomarkers as supporting evidence in an ALS study, stating that they had been burned by biomarkers too many times. (We did not pursue this discussion further since based on previous discussions, use of biomarkers at this time appears to be off the table with FDA. It seems they have no objection to collecting biomarker data – but they are not open to using them for purposes of regulatory decision-making regarding an ALS treatment.) 
On endpoints, FDA stated that they think there is significant variability in ALSFRS and FVC measurements, and stated that if FVC is selected as the primary endpoint, it would not be evaluated in a vacuum. They would be looking for concordance in other measures (e.g., they would want to see ALSFRS and other patient outcome measures generally go in a positive direction if FVC outcomes were statistically positive). 
During the meeting, HNFA expressed the following to FDA and FDA provided the following responses:• We have made clear to FDA the ALS community’s perception of risks versus benefits, and that the community considers the risks of the disease to substantially outweigh the risks of investigational treatments that, based on early data, indicate they may provide some benefit.FDA responded that they understand that the ALS community supports approval of treatments with adverse side effects if the drugs also provide some benefit.• HNFA clarified that the community extends their position on risk to FDA being open to approving drugs in an expedited manner based on limited data, and then relying on post-approval studies and registries to learn more, faster about the safety and efficacy of the treatment and how to optimize its use, even if granting the early approval might result in some treatments ultimately being found less safe or effective than originally thought, requiring re-labeling or even withdrawal from the market. Presently, PALS have almost nothing available to them and the pipeline is thin in part because of the high regulatory hurdles for ALS treatments; problems that can only be addressed through a stream-lined and expedited development and approval path. A specific recommendation that was made during the meeting was that FDA should be more flexible with its statistical significance standard (p = 0.05) for diseases like ALS with an extreme unmet medical need, which would allow for smaller, faster studies that, if positive at a lower level of statistical significance, could lead to a conditional approval (which is what accelerated approval already is), supported in the post-approval space by continued study.FDA responded in a noticeably rigid manner that it must meet its statutory standard in the Food Drug and Cosmetic Act (FDCA), and that if the ALS community wanted the standard changed, they should pursue that with Congress.[Explanation – not from FDA . The standard for approval in the FDCA is generally worded and allows broad discretion to FDA in deciding what the standard for approval should be for any drug intended to treat any disease. Congress has directed FDA to be more flexible when setting the standards for new medicines intended to treat serious and life-threatening diseases with unmet needs. ALS is among the most serious of all known diseases, and is almost universally fatal within 2 to 5 years) In our case, FDA has firmly indicated that they do not intend to be flexible.]HNFA responded that FDA has broad discretion in interpreting and applying the approval standards in the FDCA, and that Congress had already instructed them to use that discretion for new medicines intended to treat diseases like ALS.HNFA explained to FDA that our goal is to complete these discussions regarding a streamlined development and approval path for ALS drugs in a few additional weeks, then move to the next stage of proposing the pathway to sponsors for comment and potential use in starting registration clinical studies within the next few months, with the goal of completing the data collection portion of those studies by the end of this year, and that we expected FDA to partner with us in achieving this goal.In follow up communications between HNFA and FDA since the July 6th meeting, HNFA has opted to submit a conceptual study design to FDA, and FDA agreed to provide feedback within approximately one week. The conceptual study design was provided to FDA and we expected a response this week. Instead, we received an e-mail from FDA stating that they would “…like to broaden the participants so more members of the ALS community can participate and provide input.” This decision by FDA, which was made unilaterally without consultation with HNFA, appears to mean that they do not intend to respond to our proposal in a timely manner. It also means that the pace of discussions with FDA regarding the modernization and acceleration of new drug development programs for ALS will be substantially slowed, and will lose focus as “stakeholders” with goals that differ significantly from the urgent needs of PALS and CALS are selected by FDA and brought into the process.

Monday, July 20, 2015

"The Single Largest Research Project Ever Created"

Those are the words of the ALS Association regarding the CDC's ATSDR ALS Registry.  We believe in its largeness in terms of expenditure.  There are some serious questions about the largeness of the results.

This week the Registry's annual meeting is being held in Atlanta.

This twitter exchange is telling --

And finally after various advocates pressed the issue, the CDC reneged and the meeting will be webcast --

Starting Wednesday, July 22, 8:30 am EDT

I hope that people will listen in. And I hope that we never again have to ask to have any Registry meeting webcast.   There is a lot that needs to be discussed and understood, and sunshine only helps.

I hope that the following questions will be among those answered:

- As you introduce people at the meeting, will you please ask for any business relationships that the participants have with one another?  And who nominated each to participate in the meeting?  And who is paying each's expenses?

- What is the project total expenditure to-date?

- When will we have some completeness studies of the national Registry versus metro studies so that we get some insight in how many people with ALS are being missed by the national algorithm?  The "we don't know what we don't know" problem concerns many of us.

- Two years ago it was pointed out at the annual meeting that HMO data were missing from the Medicare files.  Are those the Medicare "Advantage" plans?  Do we have any reason to believe that PALS use those less than the proportions noted in this Kaiser article?  Is this a significant problem whose backbone is the idea that a very high percentage of PALS will be in government files?

- MDA indicated in the last meeting that they have around 13,000 PALS in their database.  Does that not cause concerns that an organization that sponsors only a portion of clinics has so many PALS compared with the first Registry report and compared with the annual self-enrollments?

- Last year an annual meeting participant wisely pointed out that you can't manage what you don't measure.  Surely ALSA and MDA are able to tell us how many new PALS entered their clinic systems in the past year.  How does that compare with the new self-enrollments in the Registry?

- Have ALSA and MDA ever simply sent out an email survey blast to all their PALS -- Did you self-enroll in the Registry?  If not, why not?

- Have you measured how many PALS actually enrolled in the clinical trials for which they were notified via a Registry email? The importance of this was broached in the last meetings discussion and I hope has been measured since.

- In an OMB filing, the "annual cost to the government" for the ALS Registry was given as $1,100,000 annually.  Why does that differ so from the $10 million that we request every year?

- Could we get a ballpark breakdown of the annual budget by these categories, please?

- There was a public comments period for a new outbound telephone plan within the Registry project to move non-clinic neurologists' behavior to increase self-enrollment.  What data show that telemarketing like this will change neurologists' behavior?

- Is the premise in the telemarketing plan that non-clinic neurologists are a significant factor in low PALS self-enrollment not at odds with the special status that ALSA and MDA have been given in this project because of their clinic systems?

- Would you discuss Stephen Finger's article on Registry completeness and the first prevalence report, please?

- Would you discuss Stephen Finger's comment related to the recent survival data publication from the Registry, please?

- Would you discuss why Stephen Finger was not invited to participate in the annual Registry meeting, please?

- This observation was first brought up by a PALS at the advocacy conference in May, I believe.  Metro studies are done in areas with much larger minority populations than the general U.S. population, yet Metro studies are showing more ALS than the general U.S. population.  Does that not refute the conclusions of the first national Registry report that ALS is more common in white males?

- Why are we not getting a second annual report?

- The recently published report from the biorepository study group had some votes regarding the future of this part of the Registry.  The report said that ATSDR and McKing employees were not allowed to vote. Could we find out who the 12 voters were, please?

- Could any of the collected tissue samples potentially be used to develop iPS models?

- A recently published article associated formaldehyde exposure with ALS, and funeral directors were spotlighted as being at possible risk.  When something like this is published, how long does it take for ATSDR to review the Registry self-enrollment data to see if the Registry occupational data support or refute a theory?

- If an ALS researcher requests information from the self-enrollment portal, how will those data be released?  Will any of those data be released that have not yet been matched with the government files that are several years behind?

We have advocated hard and at our own expense to get this project more than enough taxpayer dollars to fill its mission and we look forward to the discussions on Wednesday and Thursday.

Monday, July 6, 2015

Before You Put Anything Else On Your Plate...

Mom would tell you to finish your peas.

We see the buildup to a concerted effort to try a redux of the fundraising part of the ALS Ice Bucket Challenge.

I hope that every organization that tries to do this will first give us a clear accounting of what it did with its windfall funds from last year -- simply an orderly list of the checks that have cleared and what they were spent on, and what, if anything, is left in the bank.  We don't need a foggy infographic with fine print (but perhaps there will be a line item of dollars spent on those).

Do you still have peas on the plate in front of you right now?

Sometimes the fight against ALS just needs a dose of motherly common sense.


Thursday, July 2, 2015

Some Days You Just Don't Want To Enter That Maze Ever Again

Yesterday was one.

It's easy to be lured into that maze entrance with announcements and press releases and "promising" approaches.  Been there. Done that.  We always seem to get lost inside.

The Big Biomarker Trial Announcement
Boy, did that ever sound good.  Three million dollars.  Two trials. "Promising" biomarkers.  Walk right into that maze and see what a wonderful destination we find.  Whoa.  Wait a minute.  I really don't want to enter that maze if it ends up anything like our last Phase 2 trial of NP001. 
My understanding is that the $3 million in grants announced yesterday were specifically for professional CRO services from NEALS for Phase 2 trials.  That's certainly not chopped liver, but it's not flexible like cash.  Do those kinds of grants mean that investigators and drug developers and organizations will not be tempted to challenge the old Phase 2 model? 
And now we come to NP001 itself.  We already learned from Dr. McGrath's comments at the big ALS symposium in December that high LPS PALS were the responders in the old Phase 2 trial in 2011.  And we also know from experiences of PALS in that trial that some PALS experienced improvements and then had terrible crashes during the washout period where the LPS biomarker was tracked.  And no NP001 was made available to any of those trial volunteers after that. 
Will this trial be designed more humanely? 
And what will we have at the end of another long Phase 2 trial?  More certainty on biomarkers but still nothing accessible for PALS?  Will Neuraltus still be passing the tin cup to investors to come up with the $30-$35 million dollars they say they need for a Phase 3 trial? 
Urgency, anyone? 
Or are we just expected to enter the maze again and see where it takes us? 
And if anyone is worried about the dangers of GM604 if granted FDA Accelerated Approval, we can let them talk to the widows and orphans of the brave NP001 trial volunteers about safety and risk and the old approval process. 

The ALS Registry Annual Meeting
And we had an opportunity to step into yet another maze yesterday afternoon.  Per @CDCEnvironment the ALS Registry Annual Meeting will not be webcast this year because of budget limitations.  That's certainly a huge step backwards in transparency in a project that people care about.  It's also not fair to those who advocate for tens of millions of dollars for that project.  We step into another maze when we have to wait for a written report on the meeting that is published far after the fact.  We get lost when we don't see the interaction and questions and answers and project leadership dynamically. 
And we also learned yesterday from @CDCEnvironment that the annual report of Registry results that we was promised every year after the initial report last summer will be delayed.  "The 2nd & 3rd report (i.e. 2012-2013) will be combined into 1 report. Therefore, it will be released in early 2016."  Oh, it's like we just took a bad turn in the maze again. 

The shortest distance between two points isn't in a maze.   Transparency and challenges to the status quo are healthy, and you just get lost when you walk right into that adjective-laden door.

Friday, June 26, 2015

Well Done, Good and Faithful Servant

Every now and then I can just hear God's words as one of our beloved friends with ALS arrives at the pearly gates.

Chuck Hummer fought the good fight.  He lasted a long time with ALS with help from his beloved bride and family.  ALS finally won yesterday.  It always does.  But Chuck made a huge difference in lives.  ALS couldn't steal the good that he did.

Almost a decade ago the ALS Association started something called their Virtual Advocacy Community.  Chuck Hummer entered our lives.

Log in and look for OldChuck.  When I first visited that site, I seriously thought that OldChuck was ALSA's shill for their advocacy efforts. He explained and motivated. He wrote beautifully.  He treated people kindly. He was smart. He was the virtual mayor of the VAC and made it a great place for people interested in advocacy.

OC, as I called him, knew a lot.  He had a career in government work and knew the drill (and tricks) for getting funds in DC.  He had started a not-for-profit centered around his beloved Panama Canal, and he knew a lot about not-for-profit management.  And most important of all, he had been an AIDS activist with his son.  He saw that movement finally succeed, but it was too late for his dear son.  He knew much of what it would take for the fight against ALS to succeed.

So we had an awesome little VAC with quite the mayor.  ALSA had a gift.

Eventually he started challenging the status quo of 2006.  He asked questions about the return-on-investment for the big advocacy conference that ALSA held in Washington.  He pressed for bigger requests for funding.  He demanded better inter organizational coordination.  And he knew the rights of people who required accessible rooms at an ALSA-sponsored gathering.  He was pushing and pressing to improve the fight.  It was energizing.  Unfortunately ALSA never engaged in the energized VAC.

He was soon kicked out of the VAC.  Somebody at ALSA pulled out the rule book and managed to silence him.

OC felt so strongly about the cause and advocacy that he managed to sneak back into the VAC by setting up an identity with a grandchild's name.  The Washington Wizards (as he brilliantly called them after his first ejection) soon caught on and booted him again.

OC was my hero.

He was opinionated, but you didn't have to agree with him to be his friend.  ALSA missed out on a great force that could have made the fight so much better.

He was a pioneer in online peer support.  Google for gamboachuck or oldchuck or oldchuckles or grumpyals and you'll see a gentleman who was a godsend of support to hundreds of people with ALS and caregivers.

He blogged and he commented and participated in all kinds of online media.  He was kind and helpful to so many.  And could he ever write.

This morning I saw on Facebook how many people who benefited from his love and mentorship are grieving today.

You were a good egg, OC, and a Double Domer to boot.

How I miss you already.