Therapeutics

AADvac1

Overview

Name: AADvac1
Synonyms: Axon peptide 108 conjugated to KLH
Therapy Type: Immunotherapy (active) (timeline)
Target Type: Tau (timeline)
Condition(s): Alzheimer's Disease, Progressive Nonfluent Aphasia
U.S. FDA Status: Alzheimer's Disease (Phase 2), Progressive Nonfluent Aphasia (Phase 1)
Company: Axon Neuroscience SE

Background

This is an active vaccine designed to elicit an immune response against pathologically modified forms of tau protein. The approach was inspired by research on tau cleavage generating N-terminally truncated fragments (Feb 2013 newsPaholikova et al., 2015). 

The AADvac1 vaccine consists of a synthetic peptide derived from amino acids 294 to 305 of the tau sequence, i.e., KDNIKHVPGGGS, coupled to keyhole limpet hemocyanin; the precise molecular nature of the antigen has not been disclosed. AADvac1 uses aluminum hydroxide as an adjuvant. At the 2014 AAIC conference in Copenhagen, preclinical studies were reported as having met safety requirements for up to six months in rats, rabbits, and dogs; a paper reported that the vaccine reduced tau pathology and improved sensorimotor function in transgenic rats (Aug 2014 newsKontsekova et al., 2014).

Findings

In May 2013, Axon Neuroscience began a first-in-man Phase 1 trial at four sites in Austria to evaluate AADvac1 in 30 patients with mild to moderate Alzheimer’s disease. Three subcutaneous, monthly injections of a single dose were assessed for safety, tolerability, and immunogenicity; some exploratory assessment of cognition was also done. A three-month, double-blind, placebo-controlled phase was followed by another three months of open-label monthly dosing. The treatment group received a total of six injections; placebo participants received three. After that, patients could enroll in a follow-up open-label extension lasting a further 18 months.

At the July 2015 AAIC conference, the company announced results. Twenty-four patients had been randomized to AADvac-1 and six to placebo, according to Reinhold Schmidt of the University of Graz. Two withdrew due to adverse events, of whom one—a patient with a viral infection followed by epileptic seizure—was considered to be possibly related to the study medication. Overall, AADvac1 in this study was safe and well-tolerated, Schmidt said. In a majority of participants, repeat injections induced increasing antibody titers. Sera from immunized patients reacted with pathological tau from human brain. Mean ADAS-cog scores remained stable over six months. The results were later published (Novak et al., 2017).

The 18-month open-label extension enrolled 26 patients, of whom 20 completed. Antibody titers declined in the six months after last injection; booster doses restored IgG levels. The scientists saw no additional treatment-related serious adverse events, but reported a trend toward lower hippocampal atrophy and better performance on some cognitive tests in patients with higher IgG responses (Novak et al., 2018Novak et al., 2019).  

In March 2016, a 24-month Phase 2 safety trial began enrolling 185 patients with mild to moderate AD and an MRI consistent with this diagnosis. Initially, the inclusion criteria included indications of medial temporal lobe atrophy; during the study the criteria were changed to medial temporal lobe atrophy and/or a positive AD biomarker profile of amyloid and tau in CSF. The study lists 30 exclusion criteria. It compared six monthly subcutaneous injections followed by five quarterly boosters of 40 micrograms of vaccine with the adjuvant aluminum hydroxide to placebo. The primary outcome was safety; secondary outcomes included cognitive and clinical batteries as well a measure of immunogenicity. FDG PET, MRI volumetry, and CSF biochemistry were exploratory outcomes. The study was conducted in Austria, Czechia, Germany, Poland, Romania, Slovakia, Slovenia, and Sweden, and was completed in June 2019.

In a September 2019 press release, Axon Neuroscience announced initial results, and presented more details at the 2020 virtual AAT-AD/PD Focus Meeting (Apr 2020 conference news). According to their reports, there were no differences in incidence or type of adverse event between treatment and placebo groups. Of 196 participants enrolled, 163 completed. More than 80 percent of immunized participants developed high-affinity tau antibodies, which bound aggregated tau in autopsy brain tissue from AD, progressive supranuclear palsy, corticobasal degeneration, or frontotemporal dementia patients, and impeded neuronal uptake of pathologic tau in cell assays.

In this trial, AADvac-1 reportedly slowed the increase in blood NfL, a marker for neurodegeneration. In vaccinated participants, blood NfL rose 12.6 percent between baseline and two years versus a 27.9 percent rise in the placebo group (p=0.0039). Twenty treated patients and seven on placebo provided CSF. The former had a reduction of CSF pTau181 and pTau217, and stabilization of total tau, compared with placebo. In the trial as a whole, treatment produced no cognitive benefit. A preplanned age subgroup analysis indicated a trend toward slower decline with treatment than placebo on the CDR-SB, MMSE, and ADL among younger participants. In this group, treatment led to greater reductions in plasma NfL than in the group as a whole, and a statistically significant slowing of cortical atrophy. In a post hoc substudy of diffusion tensor MRI in 20 people, white-matter integrity was preserved with treatment compared with control.

In July 2017, Axon Neuroscience started a two-year, open-label Phase 1 pilot trial of two doses of AADvac1 in 33 people with nonfluent/agrammatic variant primary progressive aphasia (PPA) between the ages of 18 and 85. Participants receive either 40 or 160 micrograms of AADvac1 in a series of six subcutaneous injections spaced six weeks apart, followed by five booster shots spaced 13 weeks apart. Primary outcomes include adverse events and measures of immunogenicity such as anti-AADvac1 antibody titer and subclass. Secondary outcomes include change in CSF biomarkers such as neurogranin, phosphorylated neurofilament heavy chain protein, ubiquitin, tau, phospho-tau pT181, N-terminal tau, amyloid β1-40, amyloid-β1-42, α-, β-, and γ-synuclein, YKL-40, MCP-1; change in serum biomarkers such as neurofilament light; MRI, as well as a range of clinical measures including the Frontotemporal Lobar Degeneration Clinical Dementia Rating Sum of Boxes (FTLD-CDR-SB) and others. The trial will run at three sites in Germany until November 2020.

For details on AADvac1 trials, see clinicaltrials.gov

Clinical Trial Timeline

  • Phase 1
  • Phase 2
  • Study completed / Planned end date
  • Planned end date unavailable
  • Study aborted
Sponsor Clinical Trial 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Axon Neuroscience SE NCT01850238
N=30
Axon Neuroscience SE NCT02031198
N=30
Axon Neuroscience SE NCT02579252
N=185

Last Updated: 17 Apr 2020

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References

News Citations

  1. Active Tau Vaccine: Hints of Slowing Neurodegeneration
  2. Truncated Tau Triggers Tangles, Transmits Pathology
  3. Therapies Take Aim at Tau

Paper Citations

  1. . Safety and immunogenicity of the tau vaccine AADvac1 in patients with Alzheimer's disease: a randomised, double-blind, placebo-controlled, phase 1 trial. Lancet Neurol. 2017 Feb;16(2):123-134. Epub 2016 Dec 10 PubMed.
  2. . FUNDAMANT: an interventional 72-week phase 1 follow-up study of AADvac1, an active immunotherapy against tau protein pathology in Alzheimer's disease. Alzheimers Res Ther. 2018 Oct 24;10(1):108. PubMed.
  3. . AADvac1, an Active Immunotherapy for Alzheimer's Disease and Non Alzheimer Tauopathies: An Overview of Preclinical and Clinical Development. J Prev Alzheimers Dis. 2019;6(1):63-69. PubMed.
  4. . N-terminal truncation of microtubule associated protein tau dysregulates its cellular localization. J Alzheimers Dis. 2015;43(3):915-26. PubMed.
  5. . First-in-man tau vaccine targeting structural determinants essential for pathological tau-tau interaction reduces tau oligomerisation and neurofibrillary degeneration in an Alzheimer's disease model. Alzheimers Res Ther. 2014;6(4):44. Epub 2014 Aug 1 PubMed.

External Citations

  1. press release
  2. clinicaltrials.gov

Further Reading

Papers

  1. . Who fans the flames of Alzheimer's disease brains? Misfolded tau on the crossroad of neurodegenerative and inflammatory pathways. J Neuroinflammation. 2012;9:47. PubMed.
  2. . The self-perpetuating tau truncation circle. Biochem Soc Trans. 2012 Aug;40(4):681-6. PubMed.
  3. . Misfolded truncated protein τ induces innate immune response via MAPK pathway. J Immunol. 2011 Sep 1;187(5):2732-9. PubMed.
  4. . Tau truncation is a productive posttranslational modification of neurofibrillary degeneration in Alzheimer's disease. Curr Alzheimer Res. 2010 Dec;7(8):708-16. PubMed.