Therapeutics

Gantenerumab

Overview

Name: Gantenerumab
Synonyms: RO4909832, RG1450
Therapy Type: Immunotherapy (passive) (timeline)
Target Type: Amyloid-Related (timeline)
Condition(s): Alzheimer's Disease
U.S. FDA Status: Alzheimer's Disease (Phase 3)
Company: Chugai Pharmaceutical Co., Ltd., Hoffmann-La Roche

Background

Gantenerumab is a fully human IgG1 antibody designed to bind with subnanomolar affinity to a conformational epitope on Aβ fibrils. It encompasses both N-terminal and central amino acids of Aβ. The therapeutic rationale for this antibody is that it acts centrally to disassemble and degrade amyloid plaques by recruiting microglia and activating phagocytosis. Gantenerumab preferentially interacts with aggregated brain Aβ, both parenchymal and vascular. The antibody elicits phagocytosis of human Aβ deposits in AD brain slices co-cultured with human macrophages. It also neutralizes oligomeric Aβ42-mediated inhibitory effects on long-term potentiation in rat brains. In APP/PS-1 transgenic mice, gantenerumab binds to cerebral Aβ, reduces small plaques by recruiting microglia, and prevents new plaque formation. Gantenerumab does not alter plasma Aβ (Bohrmann et al., 2012). It has been studied as a potential combination therapy with the Roche BACE inhibitor RG7129 in mouse models of Aβ amyloidosis (Apr 2013 news).

Findings

Four Phase 1 trials conducted internationally in a total of 308 patients have tested the safety, tolerability, pharmacokinetics, and pharmacodynamics of single and multiple doses of infused and subcutaneous gantenerumab in healthy controls and people with Alzheimer's disease, respectively. Gantenerumab was generally safe and well-tolerated, but amyloid-related imaging abnormalities (ARIA) are a concern. For example, in one published study, two of six patients in the highest-dose group had focal areas of inflammation or vasogenic edema on MRI scans in brain areas with the most amyloid reduction (Ostrowitzki et al., 2012). The imaging finding was transient, but ARIA are being monitored closely with MRI in subsequent trials. One dosing study with 16 participants indicated an 11 percent difference in the amount of amyloid change between placebo and the higher dose at six months.

In 2010, Roche started a Phase 2 trial of 105 or 225 mg gantenerumab injected subcutaneously once a month into 360 participants, and in 2012 expanded the study to a Phase 2/3 registration trial of 799 people. Called SCarlet RoAD, this multinational, 159-center study of gantenerumab's effect on cognition and function in prodromal Alzheimer's disease delivered treatment for two years with the option of a two-year extension. Co-primary endpoints were the Clinical Dementia Rating Sum of Boxes (CDR-SOB) and change in brain amyloid levels as measured by PET. The trial included a PET sub-study of 90 participants. SCarlet RoAD enrolled people aged 50 and older whose memory function tested below normal on the Free and Cued Selective Reminding Test (FCSRT-IR), whose MMSE was 24 or above, whose CDR was 0.5, and who were positive on amyloid PET. This was one of first times the new diagnostic criteria by the International Working Group were applied in a large clinical trial. At the November 2014 CTAD conference, data were reported to suggest that this screening process worked to enroll a homogenous population of early symptomatic patients whose memory deficit was likely due to underlying Alzheimer's pathology (Dec 2014 conference news).

On December 19, 2014, Roche stopped dosing in SCarlet RoAD based on an interim futility analysis (Dec 2014 news). In July 2015, Roche reported no efficacy on primary or secondary endpoints in this trial, but a trend toward a benefit in the fastest progressors based on post hoc analysis (Aug 2015 conference news). Subsequent reports noted biomarker and efficacy signals on the high dose among fast progressors, and the data was formally published (Nov 2015 conference newsOstrowitzki et al., 2017). SCarlet RoAD participants who entered the open-label extension study were titrated up to 1,200 mg subcutaneous gantenerumab. The slower this titration, the less ARIA-E they experienced (Dec 2017 conference news). The open-label extension will run until July 2020.

In March 2014, Roche started a Phase 3 trial of monthly subcutaneous injections of gantenerumab in what was anticipated to be 1,000 patients with clinical diagnoses of mild AD. This trial, called Marguerite RoAD, used the ADAS-cog and ADCD-ADL as co-primary and various biomarkers and clinical/neuropsychiatric measures as secondary outcomes. On October 10, 2016, the clinicaltrials.gov entry for this study was updated to reflect that this trial had stopped enrolling at 389 participants. Roche later reported that, like SCarlet RoAD, Marguerite RoAD had failed an interim futility analysis. It was switched to an open-label extension study, with participants titrated up to 1,200 mg gantenerumab.

At the 2018 AAIC conference, Roche reported that two years of high-dose gantenerumab in the SCarlet and Marguerite RoAD extension studies lowered brain amyloid by an average of 59 centiloid on florbetapir PET, with half of the 28 participants who reached this timepoint falling below the threshold for amyloid positivity, and the rest on trajectory to do so. About one-third of participants in the extension studies developed ARIA-E; the majority were asymptomatic (Aug 2018 conference newsKlein et al., 2019).

Gantenerumab, together with Eli Lilly's solanezumab, is being investigated by the Dominantly Inherited Alzheimer Network Trials Unit (DIAN-TU) in a Phase 2/3 trial aimed at preventing dementia in 210 people who are on the path to Alzheimer’s disease due to an inherited autosomal-dominant mutation in APP, presenilin-1, or presenilin-2. This trial began as a two-year, Phase 2 biomarker study (Oct 2012 news). This trial has boosted gantenerumab and solanezumab dosing. It later converted into a Phase 3 registration trial with a cognitive endpoint measured after four years of treatment. Gantenerumab dosing was increased fivefold midway through the trial.

On February 10, 2020, DIAN-TU investigators announced the trial had missed its primary endpoint. Gantenerumab had produced no significant treatment-related change on the DIAN Multivariate Cognitive Endpoint, a composite developed for this trial (Feb 2020 news).

Additional data were presented at the 2020 AAT-AD/PD Focus Meeting. Of 194 participants, 52 received gantenerumab and 39 completed the trial. Gantenerumab treatment led to a large reduction in amyloid plaque as per PiB PET scans, and it normalized CSF Aβ42. Gantenerumab reduced toward normal elevated levels of CSF total tau and p-tau181, and slowed the rise of CSF neurofilament light (Apr 2020 conference news; Apr 2020 conference news). Analysis of the cognitive data revealed that people who were symptomatic at baseline declined over the course of the study, while those who were asymptomatic remained stable. This dichotomy lessened the power of the study to detect treatment effects. On the strength of this biomarker data, DIAN-TU and Roche invited participants from all arms of this trial to an open-label extension with high-dose gantenerumab (1,020 mg monthly) for up to three years.

In 2016, Roche started two new Phase 1 trials, both investigating subcutaneous administration of higher doses of gantenerumab, in a total of 98 healthy participants. According to published results, the procedure was safe and injection pain tolerable, opening the possibility of at-home administration (Portron et al., 2020).

On March 6, 2017, MorphoSys, which partners in the development of gantenerumab, announced Roche will start two new Phase 3 trials for prodromal or mild, amyloid-confirmed AD. GRADUATE 1 and 2 began enrolling in June 2018, each at 216 different sites worldwide, with a goal of 760 participants each. Participants will be titrated up to 1,020 mg subcutaneous gantenerumab or placebo and treated for two years, with an option to continue on open label. The primary outcome measure will be change on the CDR-SB. In March 2020, target enrollment for each trial was increased to 1,016. The trials are slated to run till 2023.

At the 2019 AD/PD conference in Lisbon, Portugal, Roche showed further analyses of the two-year data. It indicated that ARIA tends to occurs in hotspots of rapid amyloid removal, but is not required for amyloid clearance across the brain. Roche also showed how comparing titration schemes in the combined SCarlet and Marguerite RoAD open-label study informed the GRADUATE trial design of a single uptitration scheme independent of participants' ApoE genotype (May 2019 news).

In May 2020, the company began a second open-label continuation for participants in the SCarlet and Marguerite RoAD studies. The 173 participants will receive antibody every four weeks, at the dose they were on previously.

At the same time, Roche registered a rollover study for people who completed either the double-blind or open-label phases of Graduate 1 and 2. In this open-label continuation, an expected 2,032 participants will receive 510 mg of gantenerumab every two weeks. The trial will start in August 2020 and run though 2024.

For all gantenerumab trials, see clinicaltrials.gov.

Clinical Trial Timeline

  • Phase 2/3
  • Phase 3
  • Study completed / Planned end date
  • Planned end date unavailable
  • Study aborted
Sponsor Clinical Trial 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Hoffmann-La Roche NCT01224106
N=770
Washington University School of Medicine NCT01760005
N=210
Hoffmann-La Roche NCT02051608
N=1000
Hoffmann-La Roche NCT03443973
N=760
Hoffmann-La Roche NCT03444870
N=760

Last Updated: 07 May 2020

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References

News Citations

  1. Immunotherapy I: Baby Steps, but No Breakthroughs
  2. End of the RoAD for Gantenerumab? Roche Declares Prodromal Alzheimer’s Trial Futile
  3. Aducanumab, Solanezumab, Gantenerumab Data Lift Crenezumab, As Well
  4. Gantenerumab, Aducanumab: Bobbing Up and Down While Navigating Currents of Trial Design
  5. High-Dose Gantenerumab Lowers Plaque Load
  6. Four Immunotherapies Now Banish Amyloid From the Brain
  7. Topline Result for First DIAN-TU Clinical Trial: Negative on Primary
  8. In DIAN-TU, Gantenerumab Brings Down Tau. By a Lot. Open Extension Planned
  9. Confused About the DIAN-TU Trial Data? Experts Discuss
  10. Keep Your Enthusiasm? Scientists Process Brutal Trial Data
  11. First Stab at Combination Therapy Yields Additive Effect

Therapeutics Citations

  1. Solanezumab

Paper Citations

  1. . Mechanism of amyloid removal in patients with Alzheimer disease treated with gantenerumab. Arch Neurol. 2012 Feb;69(2):198-207. Epub 2011 Oct 10 PubMed.
  2. . A phase III randomized trial of gantenerumab in prodromal Alzheimer's disease. Alzheimers Res Ther. 2017 Dec 8;9(1):95. PubMed.
  3. . Gantenerumab reduces amyloid-β plaques in patients with prodromal to moderate Alzheimer's disease: a PET substudy interim analysis. Alzheimers Res Ther. 2019 Dec 12;11(1):101. PubMed.
  4. . A Phase I Study to Assess the Effect of Speed of Injection on Pain, Tolerability, and Pharmacokinetics After High-volume Subcutaneous Administration of Gantenerumab in Healthy Volunteers. Clin Ther. 2020 Jan;42(1):108-120.e1. Epub 2019 Dec 26 PubMed.
  5. . Gantenerumab: A Novel Human Anti-Aβ Antibody Demonstrates Sustained Cerebral Amyloid-β Binding and Elicits Cell-Mediated Removal of Human Amyloid-β. J Alzheimers Dis. 2012;28(1):49-69. PubMed.

Other Citations

  1. Oct 2012 news

External Citations

  1. clinicaltrials.gov

Further Reading

Papers

  1. . Combined treatment with a BACE inhibitor and anti-Aβ antibody gantenerumab enhances amyloid reduction in APPLondon mice. J Neurosci. 2014 Aug 27;34(35):11621-30. PubMed.
  2. . The potential of solanezumab and gantenerumab to prevent Alzheimer's disease in people with inherited mutations that cause its early onset. Expert Opin Biol Ther. 2018 Jan;18(1):25-35. Epub 2017 Oct 16 PubMed.
  3. . Efficacy and safety studies of gantenerumab in patients with Alzheimer's disease. Expert Rev Neurother. 2014 Sep;14(9):973-86. Epub 2014 Aug 1 PubMed.
  4. . Gantenerumab for the treatment of Alzheimer's disease. Expert Opin Biol Ther. 2012 Aug;12(8):1077-86. PubMed.
  5. . Reproductive and developmental toxicology studies with gantenerumab in PS2APP transgenic mice. Reprod Toxicol. 2017 Oct;73:362-371. Epub 2017 Jul 25 PubMed.
  6. . Profile of gantenerumab and its potential in the treatment of Alzheimer's disease. Drug Des Devel Ther. 2013;7:1359-64. Epub 2013 Nov 13 PubMed.