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      ROCK-ALS: Protocol for a Randomized, Placebo-Controlled, Double-Blind Phase IIa Trial of Safety, Tolerability and Efficacy of the Rho Kinase (ROCK) Inhibitor Fasudil in Amyotrophic Lateral Sclerosis

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          Abstract

          Objectives: Disease-modifying therapies for amyotrophic lateral sclerosis (ALS) are still not satisfactory. The Rho kinase (ROCK) inhibitor fasudil has demonstrated beneficial effects in cell culture and animal models of ALS. For many years, fasudil has been approved in Japan for the treatment of vasospasm in patients with subarachnoid hemorrhage with a favorable safety profile. Here we describe a clinical trial protocol to repurpose fasudil as a disease-modifying therapy for ALS patients.

          Methods: ROCK-ALS is a multicenter, double-blind, randomized, placebo-controlled phase IIa trial of fasudil in ALS patients (EudraCT: 2017-003676-31, NCT: 03792490). Safety and tolerability are the primary endpoints. Efficacy is a secondary endpoint and will be assessed by the change in ALSFRS-R, ALSAQ-5, slow vital capacity (SVC), ECAS, and the motor unit number index (MUNIX), as well as survival. Efficacy measures will be assessed before (baseline) and immediately after the infusion therapy as well as on days 90 and 180. Patients will receive a daily dose of either 30 or 60 mg fasudil, or placebo in two intravenous applications for a total of 20 days. Regular assessments of safety will be performed throughout the treatment period, and in the follow-up period until day 180. Additionally, we will collect biological fluids to assess target engagement and evaluate potential biomarkers for disease progression. A total of 120 patients with probable or definite ALS (revised El Escorial criteria) and within 6–18 months of the onset of weakness shall be included in 16 centers in Germany, Switzerland and France.

          Results and conclusions: The ROCK-ALS trial is a phase IIa trial to evaluate the ROCK-inhibitor fasudil in early-stage ALS-patients that started patient recruitment in 2019.

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          Most cited references19

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          ROCK inhibition in models of neurodegeneration and its potential for clinical translation

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            Inhibition of Rho kinase (ROCK) increases neurite outgrowth on chondroitin sulphate proteoglycan in vitro and axonal regeneration in the adult optic nerve in vivo.

            Inhibitory molecules derived from CNS myelin and glial scar tissue are major causes for insufficient functional regeneration in the mammalian CNS. A multitude of these molecules signal through the Rho/Rho kinase (ROCK) pathway. We evaluated three inhibitors of ROCK, Y- 27632, Fasudil (HA-1077), and Dimethylfasudil (H-1152), in models of neurite outgrowth in vitro. We show, that all three ROCK inhibitors partially restore neurite outgrowth of Ntera-2 neurons on the inhibitory chondroitin sulphate proteoglycan substrate. In the rat optic nerve crush model Y-27632 dose-dependently increased regeneration of retinal ganglion cell axons in vivo. Application of Dimethylfasudil showed a trend towards increased axonal regeneration in an intermediate concentration. We demonstrate that inhibition of ROCK can be an effective therapeutic approach to increase regeneration of CNS neurons. The selection of a suitable inhibitor with a broad therapeutic window, however, is crucial in order to minimize unwanted side effects and to avoid deleterious effects on nerve fiber growth.
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              Inhibition of rho kinase enhances survival of dopaminergic neurons and attenuates axonal loss in a mouse model of Parkinson’s disease

              Axonal degeneration is one of the earliest features of Parkinson’s disease pathology, which is followed by neuronal death in the substantia nigra and other parts of the brain. Inhibition of axonal degeneration combined with cellular neuroprotection therefore seem key to targeting an early stage in Parkinson’s disease progression. Based on our previous studies in traumatic and neurodegenerative disease models, we have identified rho kinase as a molecular target that can be manipulated to disinhibit axonal regeneration and improve survival of lesioned central nervous system neurons. In this study, we examined the neuroprotective potential of pharmacological rho kinase inhibition mediated by fasudil in the in vitro 1-methyl-4-phenylpyridinium cell culture model and in the subchronic in vivo 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine mouse model of Parkinson’s disease. Application of fasudil resulted in a significant attenuation of dopaminergic cell loss in both paradigms. Furthermore, dopaminergic terminals were preserved as demonstrated by analysis of neurite network in vitro, striatal fibre density and by neurochemical analysis of the levels of dopamine and its metabolites in the striatum. Behavioural tests demonstrated a clear improvement in motor performance after fasudil treatment. The Akt survival pathway was identified as an important molecular mediator for neuroprotective effects of rho kinase inhibition in our paradigm. We conclude that inhibition of rho kinase using the clinically approved small molecule inhibitor fasudil may be a promising new therapeutic strategy for Parkinson’s disease.
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                Author and article information

                Contributors
                Journal
                Front Neurol
                Front Neurol
                Front. Neurol.
                Frontiers in Neurology
                Frontiers Media S.A.
                1664-2295
                27 March 2019
                2019
                : 10
                : 293
                Affiliations
                Author Affiliations: Reference center for neuromuscular disorders and ALS, University Hospital la Timone, Marseille, France; Department of Neurology, University Medical Center Göttingen, Germany; Institute for Sleep Medicine and Neuromuscular Disorders, Muenster University Hospital, Münster, Germany; Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital St. Gallen, St. Gallen Switzerland; Reference Center for ALS and other Motoneuron Disorders, University Hospital Bretonneau, Tours, France; Department of Neurology, Technical University of Munich, Munich, Germany; Department of Neurology, Technical University of Munich, Munich, Germany; Department of Neurology, Alfried Krupp Hospital, Essen, Germany; Department of Neurology, Jena University Hospital, Jena, Germany; Department of Neurology, Technical University of Dresden, Dresden, Germany; German Center for Neurodegenerative Diseases (DZNE) Dresden, Dresden, Germany; Department of Neurology, University Medical Center Göttingen, Germany; Department of Neurology, University Medical Center Göttingen, Germany; Department of Neurology, University Medical Center Göttingen, Germany; Center for ALS and other motor neuron disorders, Charité–Universitätsmedizin Berlin, Germany; Department of Neurology, Hannover Medical School, Hannover, Germany; Pharmacy at the University of Leipzig Medical Center, Leipzig, Germany; Department of Neurology, University Medical Center Göttingen, Germany; Department of Neurology, University of Ulm, Ulm, Germany; Center for ALS, University Hospital Pasteur, CHU de Nice, France; University of Kansas Medical Center, Kansas City, KS, United States; Department of Neurology, University of Ulm, Ulm, Germany; Department of Neurology, University of Würzburg, Würzburg, Germany; Department of Neurology, University Medical Center Göttingen, Germany.
                [1] 1Department of Neurology, Technical University of Munich , Munich, Germany
                [2] 2Department of Neurology, University Medical Center Göttingen , Göttingen, Germany
                [3] 3Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital St. Gallen, St. , Gallen, Switzerland
                [4] 4Reference Center for ALS and Other Rare Motoneuron Disorders, University Hospital Gui de Chauliac , Montpellier, France
                [5] 5Department of Medical Statistics, University Medical Center Göttingen , Göttingen, Germany
                [6] 6Department of Neurology, Technical University of Dresden , Dresden, Germany
                [7] 7German Center for Neurodegenerative Diseases (DZNE) Dresden , Dresden, Germany
                [8] 8Department of Neurology, University of Miami , Miami, FL, United States
                [9] 9Department of Neurology, Medical University of Warsaw , Warsaw, Poland
                [10] 10Münchner Studienzentrum, Technical University of Munich , Munich, Germany
                [11] 11Pharmacy at the University of Leipzig Medical Center , Leipzig, Germany
                [12] 12Department of Neurology, University of Ulm , Ulm, Germany
                Author notes

                Edited by: Chiara Briani, University of Padova, Italy

                Reviewed by: Adriano Chio, University of Turin, Italy; Mario Sabatelli, University Cattolica del Sacro Cuore, Italy

                *Correspondence: Paul Lingor paul.lingor@ 123456tum.de

                This article was submitted to Neuromuscular Diseases, a section of the journal Frontiers in Neurology

                Article
                10.3389/fneur.2019.00293
                6446974
                30972018
                46fc654f-1159-4ecb-b9b0-0b7bd264de60
                Copyright © 2019 Lingor, Weber, Camu, Friede, Hilgers, Leha, Neuwirth, Günther, Benatar, Kuzma-Kozakiewicz, Bidner, Blankenstein, Frontini, Ludolph, Koch and the ROCK-ALS Investigators.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 24 January 2019
                : 06 March 2019
                Page count
                Figures: 1, Tables: 3, Equations: 0, References: 20, Pages: 11, Words: 8055
                Funding
                Funded by: Bundesministerium für Bildung und Forschung 10.13039/501100002347
                Award ID: 01GM1704A
                Award ID: 01GM1704B
                Funded by: Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung 10.13039/501100001711
                Award ID: 32ER30_17367
                Funded by: Ministère des Affaires Sociales, de la Santé et des Droits des Femmes 10.13039/501100006022
                Award ID: DGOS2016-SERI E-RARE
                Funded by: National Center for Advancing Translational Sciences 10.13039/100006108
                Award ID: U54 NS092091
                Categories
                Neurology
                Clinical Study Protocol

                Neurology
                amyotrophic lateral sclerosis,disease-modification,clinical trial protocol,rock inhibition,study design

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