Taltirelin

A little while ago, a member on the MJD Family forum posted about a drug called Ceredist (generic name: Taltirelin) that is only available by prescription in Japan. Her mother, who is Japanese, has taken the drug for a few years. Ceredist is manufactured by a Japanese pharmaceutical company, Mitsubishi Tanabe Pharma.

Wikipedia's entry on Taltirelin reads:

Taltirelin (marketed under the tradename Ceredist) is a thyrotropin-releasing hormone (TRH) analog, which mimics the physiological actions of TRH, but with a much longer half-life and duration of effects,^[1] and little development of tolerance following prolonged dosing.^[2] It has nootropic,^[3] neuroprotective^[4] and analgesic effects,^[5] and is primarily being researched for the treatment of Spinocerebellar ataxia.

The member who made this post was uncertain whether or not the drug had any beneficial effects on her mother but hypothesized that "it has slowed down the disease, if anything."

It might be something that an MJDer who is living Japan might consider following up on but has probably been made aware of by the physicians there already. In any case, it is reassuring to know that there is at least one pharmaceutical company that has successfully developed and marketed a drug (albeit perhaps on the palliative side) for SCA.

Voice of dissent

It has been a while since our last post. Life has lapsed into a lulling routine of Pilates classes, PT sessions and work-outs at the Y. Richard continues to make progress in his PT sessions and his stamina remains good. He has taken up Sudoku puzzles to keep his mind sharp. At the rate he's going, I won't be surprised if he achieves "grand master" standing soon!

On a different note, this past April I received an email from Fabio, the son of Nadia, a fellow Nanshan patient who passed away in June 2008 from ALS. In his email to us, Fabio asked us to read his post dated April 22, 2009 which contained an RAI (Italian TV) program that had subsequently been posted in five installments on youtube for public viewing.

It is my understanding that Fabio and Nadia worked with Beike Europe, the European branch of Beike Biotechnology in China, for their trip to China for stem cell therapy in March 2007. Fabio is among the many Italians who were dissatisfied with the lack of results and response from Beike after their trip to China. Their frustration culminated in a confrontation with a Beike Europe official on the TV program.

Since I neither speak nor read Italian, I had to get my friend, Arianna, who is Italian, to translate the program for me. Here's her synopsis:

The head of Beike Europe (who does not have a science background, he has a marketing background) is trying to defend himself from angry customers that did not obtain a result. There is a scientist who says that the problem with Beike is that it has not one clinical study published on the treatments, pre- and post comparisons, there is no data on effectiveness nor on follow-up. Another doctor (the elderly looking one) puts Beike to shame by saying that it is unethical to promise such benefits when there is no data to support it.

In her article in Macleans.ca, "To China with a cure", Alexandra Shimo wrote:

Patients, like Haas, who seem to have been helped by stem cell treatments, are often eager to share their stories. They may become advocates for the Chinese medical centres; Haas’s story is publicized on the website of the company that organized his medical tourism trip. By contrast, it’s more difficult to find people who haven’t gotten better, or are worse after spending $30,000 on an experimental procedure. This might be because they feel duped, or because the Chinese stem cell treatment emphasizes empowerment—a “you can do it attitude.” Those who can’t “do it,” who go through the rigorous training program and end up no better off, may feel unlucky, cheated, or they may take the lack of success personally and feel that they have somehow failed.

I think Ms. Shimo can rest easy knowing that there are those few who will not rest until they find the truth. However, the price of being a truth seeker is a terrible one. Fabio appeared on the RAI program with his sister. He is the earnest young man in a dark suit and red tie. One does not have to understand Italian to be touched by the pain on his face when he was reminiscing about his mother and her illness. It is an image that will haunt me for a long time.

Update on the Chantix (Varenicline) trial

Thank you to Mike Fernandes who has been keeping close tabs on the Chantix (Varenicline) trial this summer. Here's what Mike learned:

PROTOCOL SYNOPSIS STUDY TITLE

A Pilot, Randomized, Double-blind, Placebo-controlled Phase I Study to Determine the Safety and Tolerability of Varenicline (Chantix®) in Treating Spinocerebellar Ataxia Types 1,2,3,and 6

SPONSOR

National Ataxia Foundation; Bobby Allison Ataxia Research Center
(Sites: U of South Florida, U of Chicago, UCLA, Emory, U of Florida, U of Minnesota)

CLINICAL PHASE

2

STUDY RATIONALE

Spinocerebellar ataxia (SCA) is a group of inherited disorders characterized by cerebellar degeneration leading to imbalance, incoordination, speech difficulties and problems with walking.

Recently, individual case reports have suggested that Varenicline, a drug used in smoking cessation, produces substantial improvement in patients with several inherited ataxias.

A modest response was noted in 5 patients with SCA, suggesting that it is potentially efficacious in this disorder as well. Although this agent is available for off-label use, the severe side effects noted with its use and the lack of long-term toxicity data demand that it be systematically assessed. The present study will test whether Varenicline is safe and potentially efficacious in a heterogeneous cohort of adults with SCA.

STUDY OBJECTIVE(S)

The primary outcomes will be the changes in the patient’s SARA Rating Scale total score and frequency and severity of dose-limiting adverse events.

The secondary objectives of this study are to assess:

the effect of Varenicline on quality of life in patients with spinocerebellar ataxia

the effect of Varenicline on depression and anxiety ratings

the effect of Varenicline on the activity of daily living (ADL) in patients with spinocerebellar ataxia

TEST ARTICLE

Varenicline

STUDY DESIGN

This is a double-blind, parallel group, randomized, placebo-controlled, crossover pilot study

NUMBER OF SUBJECTS

40 subjects overall

6 sites

STUDY DURATION

175 days(± 3 days) per subject

Furthermore, according to Mike, this trial will not be recruiting for test subjects until this summer. Here are a few links that Mike provided to Dr. Theresa A. Zesiewicz of the University of South Florida who will be conducting the study and the study itself:

http://hsc. usf.edu/NR/ rdonlyres/ E1ABA07F- CA90-4B38- B507-E13BCA3FC29 D/0/ProtocolSynopsis.pdf

http://www.ataxia. org/research/ studies/2009/ naf-research- zesiewicz. aspx

http://health. usf.edu/medicine /neurology/ faculty/zesiewic z.htm

On a separate note, Dr. Perlman prescribed Chantix for Richard some time ago to see if it helped him. However, after taking the drug for two months, we did not note any discernible improvement. Therefore, Dr. Perlman decided to take it off Richard's meds list. She will append Richard's results to the study so that his stint and effort as guinea pig will not be wasted.

Hot off the presses from the NAF

We received the following email from the National Ataxia Foundation (NAF):

2009 Annual Membership Meeting Presentations The National Ataxia Foundation is pleased to announce that many of the power point presentations given at the 2009 NAF Annual Membership Meeting are now available on the Foundation's web site, www.ataxia.org. The 52nd NAF Annual Membership Meeting, "Climb Every Mountain," was co-hosted by the Seattle Area Ataxia Support Group and the British Columbia Ataxia Society. The meeting was held on March 20 - 22, 2009 and people from around the United States and attendees as far away as Australia and Hong Kong attended the meeting. On Thursday, March 19, 2009 seventy cyclists from Ride Ataxia III arrived at the NAF Annual Membership Meeting. They began their journey four days earlier in Portland, Oregon and rode their bikes through rain and cold to help raise ataxia awareness and funds to support important ataxia research. Friday, March 20, 2009 began with General Session speakers in the morning and "Birds of a Feather" sessions in the afternoon, followed by a Friday night reception. Saturday General Sessions continued throughout the day and ended with the traditional Saturday night banquet. Sunday continued with General Session speakers and concluded in the early afternoon. The National Ataxia Foundation wishes to extend a heartfelt thank you to the Seattle Area Ataxia Support Group and the British Colombia Ataxia Society, all the knowledgeable speakers and presenters, our wonderful volunteers, our generous donors and sponsors, exhibitors, the Doubletree Hotel, the City of SeaTac, and especially all who registered to attend this important meeting. Thank you! More information about the 2009 NAF Annual Membership Meeting will be available shortly on NAF's web site and in future issues of NAF's quarterly news publication, "Generations."

2010 Annual Membership Meeting Start making your plans for next year's meeting. The 2010 NAF Annual Membership Meeting will be held in Chicago, Illinois on March 12 - 14, 2010 at the Hyatt Regency O'Hare. More information about the meeting will be available on NAF's web site, www.ataxia.org and in future issues of "Generations." See you in Chicago!

Here's a direct link to the power point presentations from the 2009 Annual Membership Meeting:

http://www.ataxia.org/events/2009-amm-presentations.aspx

An update on JC, a fellow Nanshan MJDer

We recently came across an article in Macleans, a Canadian magazine, about Jean Christophe (JC) Haas. JC went to Nanshan Hospital in 2007, shortly after we left the facilities, to undergo stem cell treatment. We have corresponded with JC through email several times. JC and his wife, Cherie, has gone back to China since his initial treatment to get more stem cell injections. We have listed his blog on this website under "MJDers Blog about their stem cell therapy".

To China for a cure
by Alexandra Shimo
March 9, 2009
Macleans.ca

China is not normally considered a world leader in surgical advances, but according to a number of its doctors (and the Canadian patients they’ve treated), it has leapfrogged ahead in stem cell treatments. A growing number of people are travelling to China for a $30,000 experimental treatment: stem cell injections. Most, like New Brunswicker Jean Christophe Haas, 40, decide to go because they have a debilitating illness and there isn’t much that Western medicine can do for them.

Haas has Machado-Joseph disease (MJD), a terminal neuromuscular disease that affects the body in a similar way to Parkinson’s, paralyzing it gradually. Although he was diagnosed 20 years ago, it took some years for the symptoms to become noticeable. At first, only his sense of balance and his coordination were affected. Then his speech began to suffer and he started slurring his words. In 2004, he had to stop work as an army mechanic because his motor skills were no longer up to par and, in the past couple of years, he started seeing double. His family felt an overwhelming sense of panic, especially because Haas’s mother had the same disease, and his grandmother died of it. His desperation was compounded by the sense that Canadian doctors had given up on him completely; one told him there was nothing to do but to accept his fate of an early death, says his wife, Cherie Haas. “It’s awful for a young man with a family to go in and hear that. It’s heartbreaking.”

Ms. Haas searched the Web and found stories of other MJD patients who seemed to have been helped by stem cell therapy at various Chinese hospitals. Many of these good news stories are posted on personal blogs or on the websites of the clinics offering the treatments. There are thousands of these testimonials, suggesting that hundreds of people go every year, says Timothy Caulfield, Canada Research Chair in Health Law and Policy at the University of Alberta, who has published studies on this issue.

Advertising on the Internet, these Chinese medical centres promise to treat a surprisingly extensive range of diseases and conditions, including ALS, autism, brain injuries, cerebral palsy, epilepsy, multiple sclerosis, Parkinson’s, spinal muscular atrophy, septo-optic dysplasia (which can cause seeing difficulties, blindness and mental retardation), spinal cord injuries and stroke. Foreigners are a major source of funds for the clinics. Some doctors like Dr. Huang Hongyun, a neuroscientist at Beijing Xishan Hospital, have treated many patients from outside China, including some from Canada, and he has published a number of papers in Chinese medical journals tracking patients pre- and post-procedure. And yet some North American doctors are critical of how the data was compiled, and skeptical of the treatments on offer.

Once Jean Haas decided to go, he told his plans to Guy Rouleau, a neurologist at Centre Hospitalier de l’Université de Montréal, who said there were slight risks of complications, and that it would probably be a waste of money. But otherwise he didn’t try to dissuade him. Raising the money for the trip was easier than expected: much of the town of Oromocto, N.B., pitched in to raise the $30,000, with neighbours’ kids shovelling driveways to help out, and the military and community organizations hosting breakfasts and fundraisers. In April 2007, he and his wife travelled to Shenzhen, China, and stayed a little more than a month. During that time, Haas had six injections of stem cells into his spine, and an intense program of physiotherapy, exercise, massage and acupuncture. The results were immediate, he says—his balance improved just a few hours after the first procedure. Back in Canada, his neurologist confirmed that Haas had indeed gotten better: he had about 10 to 15 per cent more movement, according to Rouleau, who examined him before and after the trip. It’s difficult to speculate why this occurred, but Rouleau believes the intense physiotherapy was the primary cause.

When the couple returned from China, they wrote about their experience on the Web. Word got around, and soon hundreds of people were calling them, Cherie says. A couple whose husband had a similar neurodegenerative disease even drove from Quebec to see them, and the man subsequently decided to make the stem cell trip. Another couple flew in from Taber, Alta., and decided to go to China after seeing the home videos of Haas’s progress. Those gains were partly due to the attitude of Chinese doctors, Cherie believes. They would tell Haas to push himself to his limit and even try to “retrain his brain,” she explains. “We saw miracles while we were over there. We put the word out because I know this works.”

Even if patients experience gains, it’s important to determine whether they are from the treatment, the exercise program or a more positive frame of mind. Any advances could be merely the placebo effect, as people often feel better after being treated, even if the procedure hasn’t worked and the gains won’t last, explains John Steeves, a professor at the college for interdisciplinary studies at the University of British Columbia who specializes in spinal cord injuries. Finding out whether any treatment really works requires clinical trials, and although Dr. Huang has published the results of his trials in Chinese medical journals, this data does not conform to international standards of medical analysis. Indeed, Steeves believes Huang deliberately flouts these standards to help his bottom line. “Dr. Huang has no interest doing a valid clinical trial because if it doesn’t give him good results, his income would dry up immediately,” he says from his Vancouver office.

Patients, like Haas, who seem to have been helped by stem cell treatments, are often eager to share their stories. They may become advocates for the Chinese medical centres; Haas’s story is publicized on the website of the company that organized his medical tourism trip. By contrast, it’s more difficult to find people who haven’t gotten better, or are worse after spending $30,000 on an experimental procedure. This might be because they feel duped, or because the Chinese stem cell treatment emphasizes empowerment—a “you can do it attitude.” Those who can’t “do it,” who go through the rigorous training program and end up no better off, may feel unlucky, cheated, or they may take the lack of success personally and feel that they have somehow failed.

Missouri resident Jeff Carneal, 38, doesn’t feel like a failure, but having spent so much money, he is frustrated and disappointed. He lost the use of his legs when he fell off a stepladder while fixing his father’s barn. He has spent the past six years working with different doctors trying to learn to walk again, even flying to Quito, Ecuador, for an experimental operation (nerves were removed from his legs and grafted onto his spinal cord, which cost a lot, but didn’t really help). When a Maclean’s reporter first met Carneal at the Beijing Xishan Hospital after stem cell treatment, he was enthusiastic and believed the operation he’d had a couple of weeks earlier had alleviated some of the shearing leg pain he’d felt ever since his accident. But when contacted a few weeks after he returned to the United States, he was more downbeat, and said the operation hadn’t really made any difference.

Negative outcomes aren’t widely reported, but they are more common than the Chinese hospitals would have you think, says James Guest, a professor of neurological surgery at the University of Miami. He visited Huang in Beijing in the summer of 2004 to sample and test the fluid being injected into foreign patients. The results were inconclusive, he says. Following this, he went a step further, and examined spinal cord injury patients pre- and post-treatment in China. The results, published in 2006 in the journal Neurorehabilitation and Neural Repair, make clear the difference between what the doctors see and what patients want to believe. Of the seven, six thought they recovered some limb movement, although in most cases the physicians measured very little difference.

A few had concrete gains: a 19-year-old had chronic, burning back pain that eased enough for the patient to stop taking painkillers. Another patient had fewer muscle spasms after the procedure and could angle his left hand a little more, although he phoned Guest six months later to say the surgery had not made any permanent difference. On the downside, there were also post-treatment complications: a 22-year-old contracted meningitis, pneumonia and gastrointestinal bleeding, which were managed with heavy medications, and another had a fever and confusion along with a drug rash. Guest is critical of the Chinese stem cell treatments: he believes some doctors are “motivated by profits” and “they place patients at risk for therapies which have minimal effect.”

Eight months after travelling to China, Haas was struggling with the symptoms of Machado-Joseph disease. He was having problems walking and was falling again. The family still had some money left over from their fundraisers, so they decided to make another trip to China, and took out a small loan. In March 2008, he and his wife went to China, this time to Qingdao in eastern China—the first hospital wouldn’t accept them since it was now prioritizing Chinese nationals over foreigners, explains Cherie. After four weeks of treatment, Haas had more energy and there were slight improvements in his balance and speech, he says. However, the gains lasted all of two months and today he’s just as bad as before the first trip. Nevertheless, despite the costs, and the dubious rates of success, the family would like to return again if they could afford it. “I would go tomorrow if we could,” Cherie says. “It gave people hope.”

Day 2 and 3 of the NAF conference

Apologies for the delay in publishing this post on the rest of the NAF conference; Richard's daughter, Andrea, is guest-blogging this post after catching up with some school work.

The rest of the presentations were particularly informative with Saturday's researchers discussing how to treat the symptoms of ataxia (through medication, diet, speech therapy, etc.) and Sunday's presenters describing the latest progression in mapping the neuropathologies of certain ataxia variants and developing sophisticated new genetic treatments. Saturday's focus for participants was on dealing with the nuts and bolts, educating people with ataxia and their caregivers to manage the effects of the disease. We also learned about a couple of clinical trials, such as an upcoming Chantix trial (yes, the anti-smoking drug) that will soon commence.

Medication management is a particular concern given that improper dosages can cause adverse side effects for people with sensitive nervous systems as is the case for ataxics; when in doubt, start off with the lowest dosage possible and work your way up. Certain symptoms such as fatigue may be drug side effects, rather than a result of the disease itself; if you notice a change in functioning or how you're feeling, take note of any changes in your medications and let your doctor know. Over the counter medications, "natural remedies" and supplements should be reported to your primary care physician and neurologist, too, as these do have biochemical effects that may interact with other drugs that you're taking. Supplements such as antioxidants CoQ10 and Idebenone have been heavily marketed for those with a variety of neurodegenerative diseases, but their efficacy is somewhat questionable at the present, especially given that they are quite expensive.

The highlight of the final day was Dr. Ryan Boudreau's presentation on RNAi for SCA-1, though numerous others such as Dr. Henry Paulson are currently working on RNAi therapies for other ataxia variants. Dr. Boudreau and his collaborators have been testing the delivery of inhibitory RNA that "turns off" the SCA-1 gene producing the toxic protein hastening the neuronal death in the cerebellum. Current issues involve ensuring the safe delivery of the RNAi via a non-pathogenic virus; "more is not necessarily better," as Dr. Bourdreau pointed out, as silencing genes with these engineered RNAi may inhibit other genes not meant to be interfered with. They are also investigating the site of delivery to see if the therapeutic effects can be enhanced by affecting a greater portion of the cerebellum. It will be interesting to see what the long term effects of RNAi therapy are, if the improvement in behavioral functioning as well as in halting the progression of the disease can be upheld.

The quantity of medical information, with one presentation after another, was quite a bit to process although the researchers took great care to make sure that they were clearly communicating the more technical aspects of their presentations. The intellectual sophistication of the conference proceedings gave this college student a mental workout during her spring break, a testament to the researchers' generosity in sharing their findings and willingness to outreach to the ataxia community. I can only imagine how intimidating the volume of neurogenetic and biochemical terminology felt for other laypeople like myself who haven't taken college biology (or don't remember the subject). If I weren't English language proficient and the beneficiary of a good education, I don't think I would've been able to understand even a third of what was presented.

Having these conferences and keeping the ataxia community aware of the latest progress are unquestionably necessary, but we must also consider who within the community is able to absorb the nuances of disease etiology and symptom management, pursue the most effective treatment strategies, and have the means to do so.

With the current economic climate, we suspect that fewer people were able to attend this year's conference. Those weren't able to attend this year, as well as previous years', probably have more limited resources, which may affect their ability to continue managing their ataxia and seek medical help. We wonder about how these breakthroughs in biomedical research can be best disseminated to those affected by ataxia but who are unaware of its progression or even the many avenues for treating symptoms in the meantime.

Ataxia is an equal opportunity disease that affects people of all racial/ethnic and class backgrounds; unfortunately, not everyone is able to receive good care and sufficient support in handling everyday life with this disease. Addressing barriers to accessing medical information, treatment options, and health care in general must become a priority if we are going to help everyone who is affected by this disease. Raising ataxia's profile in the public and medical arena, including through the annual NAF conference, is a crucial first step. We are grateful for the support and advice we have received from fellow participants during the conference, swapping stories person to person about our experiences with the disease, learning from each other about remedies we didn't know about, and finding new sources of hope and inspiration.

We can only hope that this blog can serve at least some small role in disseminating information about ataxia to those in need of it.

Day 1 of the NAF Conference: it’s always drizzly in Sea-Tac

Andrea is guest blogging with Richard in covering this year’s National Ataxia Foundation conference in Seattle (or more specifically, Sea-Tac, as the city’s mayor kindly pointed out as he welcomed the participants this morning). Spending the latter portion of my spring break here has been as educational as being in class. The opening lecture, reviewing the genetic basis of ataxia, compacted “3 years worth of cellular biology,” in Dr. Perlman’s words. Dr. Laura Ranum used the apt metaphor of drinking from a fire hydrant to describe the knowledge influx in medical research. At the top of the research agenda is integrating the findings from all these molecular genetic and neuropathological studies into understanding how to treat the various types of ataxia.

Ataxia experts Dr. Ranum, Dr. Harry Orr and Dr. SH Subramony, succinctly discussed upcoming trends in ataxia studies, with basic scientific research evolving into transitional research. Ataxia research has promising new avenues for funding, which is critical for these medical investigations to progress. Despite the woes of the current economic climate, the NIH has received an additional $8.2 billion for clinical and translational research, among other areas of medical interest. So far this year, 9 approved research grants, out of 48 applications processed, will be receiving $484,000 from the NAF. Researchers want to capitalize on the $1 million NIH challenge grants with an unprecedented, accelerated funding approval process; these challenge grant studies should be starting earliest 9/30/09. We’ll be staying tuned for tomorrow’s presentations focusing on these individual experts’ upcoming trials and how ataxia patients can become involved.

The conference has engaged much peer-to-peer interaction and education. Researchers lucidly presented this complex material to the general audience of patients and caregivers, as well as updating their fellow experts about developments in the field. Kudos to Corrie Smith’s presentation on genetic testing for being extremely accessible and thoughtful in considering the complexity of ethical implications involved for all parties. The “Birds of a Feather” breakout sessions were particularly valuable, with each session focusing on a different group affected by ataxia so that caregivers, people with SCA 3, individuals with Friedrich’s, etc. could discuss their experiences with each other. In between workshops and presentations participants were mingling with each other, discussing their experiences with various physical therapies, diet/supplement regimens, drugs and other treatments and recommending what they had found effective.

The accommodations at the Doubletree have generally been accessible: the low-pile carpets are wheelchair-friendly, there are plenty of places to sit along the hallway, and most of the workshops have been on the first floor. The booths outside the main presentation area featured all sorts of useful pamphlets and booklets, local support services for Washington area ataxia patients, and opportunities for attendees to participate in some new studies on the spot. If you’re a conference attendee reading this and have some time tomorrow, please stop by UC Berkeley research coordinator Nola Klemfuss’s experimental set up. She’s conducting non-invasive, physically undemanding studies on visuo-motor coordination and could really use some more folks to participate. Compensation is $20/hour, and participation takes about 1.5 hours. Richard participated in her study and can vouch that it’s interesting.

We look forward to keeping you posted on the latest clinical trials and RNAi research in the next two days.