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Innovating Clinical Trials for Amyotrophic Lateral Sclerosis: Challenging the Established Order

Research output: Contribution to journalArticlepeer-review

Ruben P.A. van Eijk, Stavros Nikolakopoulos, Kit C.B. Roes, Lindsay Kendall, Steve S. Han, Arseniy Lavrov, Noam Epstein, Tessa Kliest, Adriaan D. de Jongh, Henk Jan Westeneng, Ammar Al-Chalabi, Philip Van Damme, Orla Hardiman, Pamela J. Shaw, Christopher J. McDermott, Marinus J.C. Eijkemans, Leonard H. van den Berg

Original languageEnglish
Pages (from-to)528-536
Number of pages9
Issue number11
Published14 Sep 2021

Bibliographical note

Publisher Copyright: Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

King's Authors


Development of effective treatments for amyotrophic lateral sclerosis (ALS) has been hampered by disease heterogeneity, a limited understanding of underlying pathophysiology, and methodologic design challenges. We have evaluated 2 major themes in the design of pivotal, phase 3 clinical trials for ALS-(1) patient selection and (2) analytical strategy-and discussed potential solutions with the European Medicines Agency. Several design considerations were assessed using data from 5 placebo-controlled clinical trials (n = 988), 4 population-based cohorts (n = 5,100), and 2,436 placebo-allocated patients from the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) database. The validity of each proposed design modification was confirmed by means of simulation and illustrated for a hypothetical setting. Compared to classical trial design, the proposed design modifications reduce the sample size by 30.5% and placebo exposure time by 35.4%. By making use of prognostic survival models, one creates a potential to include a larger proportion of the population and maximize generalizability. We propose a flexible design framework that naturally adapts the trial duration when inaccurate assumptions are made at the design stage, such as enrollment or survival rate. In case of futility, the follow-up time is shortened and patient exposure to ineffective treatments or placebo is minimized. For diseases such as ALS, optimizing the use of resources, widening eligibility criteria, and minimizing exposure to futile treatments and placebo is critical to the development of effective treatments. Our proposed design modifications could circumvent important pitfalls and may serve as a blueprint for future clinical trials in this population.

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