SOW - Phenserine ECRT Clinical trial - 75N95022R00041.pdf

STATEMENT OF WORK (IDIQ)

Clinical evaluation of Phenserine tartrate Extended Controlled Release Tablet (ECRT) formulation in early mild Alzheimer’s disease and mild to moderate traumatic brain injury

I. BACKGROUND AND INTRODUCTION

There is a significant unmet need for Alzheimer’s disease therapeutics as well as drugs that favorably impact the consequences of brain injury as it can initiate cascades of biological events that may lead to long-term neurodegenerative disorders such as Alzheimer’s disease. The focus of this contract is to evaluate a promising candidate that may provide beneficial actions to both disorders.

This contract is to evaluate pharmacokinetic and pharmacodynamic measures of (-)- Phenserine tartrate Extended Controlled Release Tablet (ECRT) formulation in subjects with early mild Alzheimer’s disease (AD) in a phase 1/2 clinical trial and in mild to moderate traumatic brain injury (TBI) subjects in a phase 1/2 clinical study. Specifically, the contract is to provide clinical services for the approved administration of drug to two well-characterized patient populations, and to obtain blood and other sample/measures from them under rigorously safe conditions for later evaluation of pharmacokinetic and pharmacodynamic measures associated with drug plasma concentrations, blood markers of drug action, tolerability and brain/blood markers of efficacy.

A. Aims of contract:

The aim of this contract is to first obtain regulatory and IRB approvals for, and then to undertake a multiple ascending dose (MAD) clinical study to evaluate the safety, tolerability, and time-dependent pharmacokinetics/pharmacodynamics (particularly acetylcholinesterase (AChE) inhibition) of phenserine tartrate ECRT. Thereafter, with an understanding of the optimal dose, to safely and rapidly titrate up to this optimal dose and evaluate this optimal dose of phenserine tartrate ECRT over an extended time in two patient populations: AD and TBI subjects. Dosing for TBI subjects will be for up to 30 days and, thereafter, the subjects will be followed – alongside a matching group of ‘placebo’ subjects that will be provided best non-pharmacological care (i.e., without phenserine tartrate ECRT). Dosing of AD subjects will be for up to 52 weeks (depending on the availability of phenserine tartrate ECRT) – alongside a matching group of placebo subjects that will be administered a standard dose of the drug donepezil (instead of Phenserine tartrate ECRT).

The study will be focused on monitoring safety to achieve an optimal/maximally tolerated Phenserine tartrate ECRT dose (that does not cause unacceptable side effects or overt toxicity) and obtaining blood samples to support pharmacokinetic (e.g., drug levels of primary drug and select major metabolites) and biomarker analyses (e.g., exosome biomarkers of (i) cell death pathways, (ii) Alzheimer’s disease markers, (iii) synaptic markers and (iv) neuroinflammation markers) – involving assays that will be conducted in other labs (not within this contract).

However, clinical (computerized neuropsychology) and imaging outcomes on enrolled participants in the AD and TBI trials will be undertaken within this contract. Additionally, rapid assay of red blood cell acetylcholinesterase inhibition is an essential requirement of the contract, particularly within the MAD portion of the study, to ensure that phenserine tartrate ECRT dosing maximally achieves approx. 45% to 50% inhibition but, importantly, does not exceed 55% inhibition.

B. Background Alzheimer’s disease: Alzheimer’s disease (AD) is the most common neurodegenerative disorder worldwide. In the US alone, an estimated 5.8 million people aged 65 and older were affected in 2020, which is projected to increase to 13.8 million by 2050 [Liesi et al., 2013]. Because of the significant health, social and economic burden associated with the disease, there have been numerous attempts to find a pharmacologic treatment able to effectively delay or prevent the onset and development of pathology. Despite these efforts, the clinical trial failure rate remains extremely high. The few currently approved AD drugs address symptomatic issues. Being able to mitigate the cognitive impairment characteristic of the disorder only temporarily; they are not effective in stopping or reversing disease progression (Pangalos et al., 2007; Mehta et al., 2017;

Lao et al., 2019).

Traumatic brain injury (TBI) is a major cause of death and long-term disability, with in excess of 10 million people suffering a TBI annually worldwide – with some 1.6 to 3.8 million cases occurring in the US, alone [Mckee et al., 2015] . The preponderance of TBIs are mild to moderate in nature, representing 80–95% of cases, with severe TBI compromising the rest. With increased survival following original injury, TBI may elicit significant and lifelong cognitive, physical, and behavioral deficiencies that necessitate long-term care [LoBue et al., 2019;

Pavlovic et al., 2019]. Indeed, TBI represents a progressive process rather than a single event and is one of the most important risk factors for later development of dementia, particularly AD and Parkinson’s disease [Gardner and Yaffe 2015], associated with changes in gene expressions in pathways that lead to these disorders [Tweedie et al., 2016; Tweedie et al., 2013]. The reported increased incidence of TBI [Coronado et al., 2015] has led to estimates that by 2020, TBI will comprise the third largest global disease burden [Dewan et al., 2018].

Phenserine: The focus of this contract is to evaluate select pharmacodynamic and pharmacokinetic measures of an Alzheimer drug, (-)-Phenserine tartrate ECRT, in (i) the early mild AD state and (ii) in mild to moderate TBI. The study in the TBI population is to aid in the interpretation of the drug evaluation in AD subjects, as the neuronal cell dysfunction and death that accompanies TBI (and associated neuroinflammation and other related processes) are initiated by the injury – and, hence, are “synchronized” time-dependently. This contrasts with the same processes in AD – which represents a chronic disorder in which these processes do not occur in synchrony.

Clinical services are required by a team with specific knowledge and background in (i) the patient populations (AD and TBI), (ii) the drug class being evaluated (agents that mitigate neuronal cell dysfunction/death together with anticholinesterases), as well as (iii) on the specific drug of interest (Phenserine tartrate), to ensure rigorous safety in its administration and dose escalation, and optimization in patients to provide required blood samples and related materials that will be provided to the contractee.

Preclinical: Phenserine tartrate was initially developed and evaluated as a cholinesterase inhibitor (Greig et al., 2005: https://pubmed.ncbi.nlm.nih.gov/15974893/) but there are several mechanisms by which the drug phenserine may act on neuronal and synaptic loss, key common https://pubmed.ncbi.nlm.nih.gov/23390181/ https://pubmed.ncbi.nlm.nih.gov/25702209/ https://pubmed.ncbi.nlm.nih.gov/31282414/ https://pubmed.ncbi.nlm.nih.gov/30929221/ https://pubmed.ncbi.nlm.nih.gov/25748121/ https://pubmed.ncbi.nlm.nih.gov/27254111/ https://pubmed.ncbi.nlm.nih.gov/23454194/ https://pubmed.ncbi.nlm.nih.gov/23454194/ https://pubmed.ncbi.nlm.nih.gov/25955705/ https://pubmed.ncbi.nlm.nih.gov/29701556/ https://pubmed.ncbi.nlm.nih.gov/15974893/ pathways evident in Alzheimer’s disease, traumatic brain injury and other neurodegenerative diseases. A range of pre-clinical studies indicate that phenserine suppresses interleukin-1b, reduces glutamate-induced excitotoxicity, protects against H2O2- induced oxidative toxicity, reduces A-beta levels, improves neural precursor cell viability, elevates neurotrophic brain-derived neurotrophic factor, and inhibits APP and α-synuclein synthesis (Ballard et al., 2020:

https://pubmed.ncbi.nlm.nih.gov/32939050/). Whilst these potential actions are of interest, more significantly recent work has suggested that phenserine may confer significant neuroprotection by inhibiting apoptosis through actions on a Pre-Programmed Cell Death Pathway (Lecca et al., 2019: https://pubmed.ncbi.nlm.nih.gov/31295555/). This has been evaluated in several rodent models of neuronal loss, including APP/PSEN1 transgenic AD mice, re-perfusion injury and a weight drop mouse model of traumatic brain injury. In all of these animal studies, treatment with phenserine significantly reduced neurodegenerative lesions, and decreased the neuro-inflammatory response through IBA1 and TNF-α pathways in both wild type and Alzheimer transgenic mice (Greig et al., 2020: https://pubmed.ncbi.nlm.nih.gov/31828969/). Synaptic density and synaptophysin levels were also significantly protected in phenserine treated Alzheimer transgenic and traumatic brain injury (TBI) animals.

Clinical: (-)-Phenserine tartrate has been evaluated as an “immediate release” formulation in several trials in people with mild to moderate AD. A phase 2, twelve-week RCT indicated that (- )-phenserine (5-10 mg b.i.d.) had a favourable safety profile and conferred significant improvements in cognitive function with related improvements in cerebral glucose metabolism.

However, in these studies as well as in a phase III trial, Phenserine was not administered in a manner to maintain steady-state therapeutic levels – even though some benefits were evident at a dose of 15mg BID. The results are hence difficult to interpret on the basis of preliminary reports, especially as several studies were significantly under-powered for cognitive and functional outcomes.

Overall, there is strong nonclinical evidence of biological effects that are relevant to the treatment of Alzheimer’s disease and other neurodegenerative conditions, with a novel effect on apoptosis and a good clinical safety profile, but the potential for clinical benefit has not been evaluated in an adequately powered trial and the potential for disease modifying actions need to be confirmed in human studies.

The current contract will evaluate a new Extended Controlled Release Tablet (ECRT) formulation of (-)-Phenserine tartrate – and will evaluate (i) it’s ability to maintain steady-state therapeutic levels in early mild AD subjects following different doses, (ii) Its short-term ability to impact select markers: specifically, red blood cell (RBC) acetylcholinesterase inhibition levels (AChEI) – as a rapid marker of safe drug levels (levels of RBC AChEI – together with lack of adverse events (AEs) will define safe dose escalation to an optimal level of approx. 45 to 50% AChEI), (ii) exosome markers of (a) apoptotic/pro-survival proteins, (b) AD markers, (c) synaptic and (d) neuroinflammatory processes. (iii) Longer term markers of the same, as well as of cognitive and imaging outcomes.

An alike clinical evaluation will be undertaken in mild to moderate TBI patients with ECRT (-)- Phenserine tartrate. The same bank of exosome markers will be evaluated – with the exception that select markers of TBI (such as GFAP/Neurofilament, etc.) will be evaluated in leu of select AD markers – but, otherwise, dose escalation based on steady-state RBC AChEI measures, pharmacokinetic and exosome sampling as well as cognitive evaluations will be performed https://pubmed.ncbi.nlm.nih.gov/32939050/ https://pubmed.ncbi.nlm.nih.gov/31295555/ https://pubmed.ncbi.nlm.nih.gov/31828969/

C. NIA Activities The NIA provides direct support for clinical research and clinical research networks that focus on particular diseases or public health issues. One of the goals of NIA is to conduct research to better understand the effects and effectiveness of pharmaceuticals on neurodegenerative disorders and, in particular, AD. This Contract will ensure that NIA is able to evaluate the potential of the candidate AD drug Phenserine ECRT in relation to pharmacokinetic and pharmacodynamic measures in relation to achieving steady-state drug concentrations of the agent, and measures of drug/target engagement and efficacy when optimally dosed. Plasma samples obtained from the contract will be evaluated both at NIA and by other organizations to quantify drug concentrations as well as markers of drug action. These will be related to tolerability and cognitive/imaging measures obtained within the present Contract.

I. SCOPE AND OBJECTIVES

The main objective of this Contract is to provide a service to perform a phase 1/2 clinical trial evaluation of Phenserine tartrate ECRT in subjects with early mild Alzheimer’s disease and in mild to moderate traumatic brain injury. Specifically, the Contract will perform clinical services to provide brain imaging, cognitive assessment as well as blood and other samples to support evaluation of pharmacokinetic and pharmacodynamic measures. This will involve a multiple ascending dose (MAD) study of Phenserine ECRT, and then the selection of the optimal dose of drug to carry forward into a longer-term analysis of early efficacy.

III. TECHNICAL REQUIREMENTS

Independently and not as an agent of the Government, the Contractor shall furnish all the necessary resources, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government under the terms of this Contract, as needed to perform the technical requirements outlined below through the individual Task Orders (TOs). Phenserine ECRT will be provided to the Contractor – as will Phenserine immediate dose formulation (if required within the TBI portion of the study – to achieve a more immediate steady-state blood level).

A. Specific Focus Areas

1) Core Function Activities

Specifics:

(the information below can be expanded, as required, by contacting Dr. Nigel H. Greig (NIA,NIH:

GreigN@grc.nia.nih.gov) – who will oversee the contract from the ‘scientific perspective’).

Proposed Clinical Trial Services: Following regulatory and other required approvals, subjects, qualifying and giving informed consent, will be randomly assigned to treatment conditions: up to 40 clinical trial subjects. Additional subjects may then be assessed, as needed, to estimate power for future clinical studies.

(i) Alzheimer’s disease clinical study All AD patients will discontinue their AChE inhibitor, donepezil or other, for one week. Subjects will then receive their randomly assigned treatment of the previous dose of donepezil or donepezil mailto:GreigN@grc.nia.nih.gov

10 mg. q. d. or ECRT (-)-Phenserine tartrate (PhenT) according to treatment assignments. Since biomarkers are the outcome, double-blinding is not required. PhenT will be dosed with a stepwise increase weekly* - until 45 to 50% AChE inhibition is achieved (red blood cell assay);

thereafter, this dose will be carried forward for a minimum of 26 weeks (except in the case of toxicity – where a dose reduction will occur). The ideal total time of dosing is 52 weeks – but this time is dependent on the availability of Phenserine ECRT to provide 52 weeks of dosing at the optimal dose.

AD subjects: Dosing = 26 weeks (assessments: weekly to 30 days, and then 90 days, 26 weeks and potentially longer (specifically 52 weeks - depending on available drug)). If sufficient Phenserine ECRT is available at the optimal dose, then dosing will be continued to 52 weeks and assessments will be made at 30 days, 26 weeks and 52 weeks (instead of 30 days, 90 and 26 weeks).

Study Days Dosing Schedule* PhenT Daily Dose

(Release: mg/hr) AChE Activity+

0. Holiday Week

No AChE drug dosing for one week prior to drug.

x*+

1. PhenT

ECRT

Donepezil

One x 20 mg ECRT q.d.

At clinically indicated doses

1/3 Predicted Required Daily Dose x*

2. PhenT

ECRT

Donepezil

One x 20 mg ECRT bid At clinically indicated doses

2/3 Predicted Daily Dose x*

3. PhenT

ECRT

Donepezil

One x 20 mg ECRT tid At clinically indicated doses

3/3 Predicted Daily Dose x*

4. PhenT

ECRT

Donepezil

Two x 20 mg ECRT bid At clinically indicated doses

4/3 Predicted Daily Dose x*

5. PhenT

ECRT

Donepezil

Two x 20 mg ECRT bid At clinically indicated doses

4/3 Predicted Daily Dose x*

*Weekly Dose Escalation + At baseline prior to dosing, a blood sample for AChE activity will be withdrawn coordinated with blood draw for exosome and blood-based research and safety studies.

Outcome Measures that Services will be focused towards:

Study

Days 0-30 (dose escalation every week until optimal dose identified (~50% AChE inhibition) – as evaluated by REQUIRED in house AChEI assay (Ellman or other assay - to be agreed with Dr. Greig

(NIA, NIH).

Assessments Qualification Prior to Week 1, Baseline and under each steady-state to End

Qualifying Assessments x Inclusion and Exclusion Criteria x

Informed Consent x Cambridge Cognition AD

Outcome Battery x x

*ADAS-Cog ? (or agreed alternative) ?

*MMSE ? (or agreed alternative) ?

*ADCS-ADL X (or agreed alternative) x Exosome Sourced PNCD and other pathology outcomes x x

TEAEA. Adverse Events x x

Clinical services will provide time-dependent blood samples to support measurements for Primary biomarker assays that will be indicators of reduced Pre-programmed Neuronal Cell Death (PNCD) activities (a MINIMUM of 1 ml plasma sample (2x 0.5 ml) will be provided by Contractor: Plasma neural- and astrocytic-derived extracellular vesicle (NEV and AEV) preparations will be isolated from plasma samples to allow the following assays – which will be sent to Dr. Greig to undertake (NIA/NIH: Greign@grc.nia.nih.gov) Five panels of markers will be evaluated in samples at labs within NIA*

• PNCD: such as BAX, Bcl-2 and related family proteins, pro-caspase-3, AIF

(ELISA)

• Synaptic: such as synaptotagmin, synaptophysin, synaptopodin, PSD-95, neuronal pentraxin 2 (ELISA)

• Inflammatory: such as TNF-α, IFN-γ, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL- 12p70, IL-13 (Meso Scale Discovery multiplex assay)

• AD: such as APP, Aβ1-42, Tau, P-T181-tau and P-S396-tau (ELISA)

• Cell survival factors: such as LDLRP-6, heat-shock factor-1, and repressor element 1-/STF (ELISA).

To be undertaken by Contractor: Brain imaging (FDG PET brain imaging x2 or alike brain imaging - to be agreed with Dr. Nigel Greig (NIA/NIH: Greign@grc.nia.nih.gov)

ESSENTIAL Clinical Services to be undertaken by Contractor:

Rapid AChE assay (Ellman) – to define levels of red blood cell AChE inhibition to ensure the safety of the drug study with (-)-Phenserine tartrate ECRT – this is required to be a RAPID “IN HOUSE” ASSAY (and must be performed within a week of each dose escalation to define the steady-state level of erythrocyte AChE inhibition (to monitor and keep it below 55% inhibition – optimally at 45%-50% inhibition).

Pharmacokinetic samples require to be collected by the Contractor to allow assay for:

Phenserine (P), N1 Nor P, N8 Nor P, N1,N8 Bisnor P. These samples (plasma) will be mailto:Greign@grc.nia.nih.gov collected under steady-state conditions by the Contractor, and plasma will be frozen to - 80o C for pharmacokinetic assays that will be performed elsewhere under a separate contract. A plasma sample (0.5 ml) will be collected for each PhenT dose – and will be kept frozen (-80 C) and provided via Dr. Nigel Greig (NIA/NIH:

Greign@grc.nia.nih.gov) to a contract company for LC/MS analysis (assay of drug concentrations does NOT fall under this current contract).

(ii) TBI clinical study Mild to moderate TBI subjects within 24 hr of injury, qualifying and giving informed consent (20 TBI subjects minimum), will be randomly assigned to treatment conditions. Additional subjects may then be assessed, as needed, to estimate power for future clinical studies.

Subjects will receive their randomly assigned treatment of the best available non-pharmacological care (i.e., placebo) or ECRT Phenserine (PhenT) according to treatment assignments. Since biomarkers are a key outcome, double-blinding is not required. PhenT will be dosed with a stepwise increase weekly* - until 45 to 50% AChE inhibition is achieved;

thereafter, this dose will be carried forward to 30 days. Thereafter pharmacological treatment will cease; however, both groups of subjects will be followed for 1 year.

In synopsis, as shown in the Table below, TBI subjects: 30 days treatment with placebo or ECRT PhenT in increasing doses (assessments will be made: weekly to 30 days; with follow up: 90 days, 1 year).

Study Days Dosing Schedule* PhenT Daily Dose

(Release: mg/hr) AChE Activity+

0. Patient recruitment

Rater-blinded randomization to either PhenT or placebo x**

1. PhenT ECRT Placebo

One 20 mg ECRT q.d.

Current treatment practice

1/3 Predicted Daily Dose x*

2. PhenT ECRT Placebo

One 20 mg ECRT bid Current treatment practice

2/3 Predicted Daily Dose x*

3. PhenT ECRT Placebo

One 20 mg ECRT tid Current treatment practice

3/3 Predicted Daily Dose x*

4. PhenT ECRT Placebo

Two 20 mg ECRT bid Current treatment practice

4/3 Predicted Daily Dose x*

5. PhenT ECRT Placebo

Two 20 mg ECRT bid At clinically indicated doses

4/3 Predicted Daily Dose x*

*Weekly Dose Escalation (1 thru 5) + At baseline prior to initial dosing, a blood sample for AChE activity will be withdrawn coordinated with a blood draw for exosome and blood-based research and safety studies.

Thereafter, alike samples will be taken for each dose-escalation and an AChE inhibition assay will be performed by the Contractor in “real time” to allow safe and ‘informed’ dose escalation up to 45%-50% erythrocyte AChE inhibition under steady-state conditions (importantly, AChE erythrocyte inhibition should not exceed 55%) – The optimal dose will be taken forward to 30 mailto:Greign@grc.nia.nih.gov days total treatment (at this point drug treatment will end and ‘follow up’ will be initiated).

Follow up at 90 days and 26 weeks will be undertaken by the Contractor in the event that the AD portion of the study last for 26 weeks total. However, follow for the TBI study will be at 26 and 52 weeks in the event that the AD portion of the study last for 52 weeks total.

2) ESSENTIAL Requirements:

ESSENTIAL study Requirements from Contractor importantly must include:

(i) Extensive background in successful clinical studies involving Alzheimer’s disease – must demonstrate with peer reviewed publications in Pub Med.

(ii) Contractor MUST have previous experience with (-)-Phenserine tartrate – must demonstrate with peer reviewed publications in Pub Med that specifically relate to “Phenserine”.

(iii) Contractor MUST have inhouse rapid assay for quantifying red blood cell AChE inhibition levels (as this is a quick assay to monitor that safe levels of (-)-phenserine are achieved) – as evidenced by Pub Med publications on cholinesterase evaluation in humans.

(iv) The Contractor’s Institution can take up to BUT NO MORE THAN 8% of the contract as overhead charges (if outside the USA) and up to BUT NO MORE THAN 10% of the contract as overhead charges (if inside the USA).

(v) The Contractor must be able to demonstrate regulatory authority experience in the field of neurodegenerative disorders (emphasizing AD), as the contract relates to human clinical evaluation of a new experimental drug. A strong preference will be provided to Contractors able to definitively demonstrate that they have previously interacted with their country’s regulatory authority in relation to (-)-phenserine tartrate

(vi) An additional preference is for a “single site” – whereby all required clinical and administrative services are provided by a ‘single’ highly experienced clinician scientist + supportive team at one site to maximize patient safety and minimize variance in the required services provided. In the event that this cannot be achieved, then preference will be provided to a Contractor meeting the other essential requirements that can undertake the required work within two or three sites.

3) Anticipated period of performance: The anticipated period of performance is 30 months ordering period.