Publication: November 3, 2020
The Twilight Zone: Benefit, Risk & Hope in Clinical Trials for
Fibrodysplasia Ossificans Progressiva (FOP)
From The International Clinical Council on FOP (ICC)
Frederick S. Kaplan1, Mona Al Mukaddam2, Genevieve Baujat3, Amanda Cali4, Tae-JoonCho5, Carmen L. De Cunto6, Patricia Delai7, Robert J. Diecidue8, Maja DiRocco9, Clive Friedman10, Zvi Grunwald11, Nobuhiko Haga12, Edward C. Hsiao13, Richard Keen14, Rolf Morhart15, J.Coen Netelenbos16, Christiaan Scott17, Michael A. Zasloff18, Keqin Zhang19, Elisabeth M. W. Eekhoff20 and Robert J. Pignolo21
1Departments of Orthopaedic Surgery, Medicine, and The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA USA
2Division of Endocrinology, Diabetes and Metabolism, Departments of Medicine and Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, USA
3Centre de Référence Maladies Osseuses Constitutionnelles, Departement de Génétique, Hôpital Necker-Enfants Malades, Institut Imagine, Paris, France
4Radiant Hope Foundation and the Ian Cali FOP Research Fund, PENN Medicine, Center for Research in FOP & Related Disorders
5Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, South Korea
6Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
7Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa, São Paulo-SP, Brazil
8Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
9Unit of Rare Diseases, Department of Pediatrics, IRCCS Giannina Gaslini Institute, Genoa, Italy
10Schulich School of Medicine and Dentistry, Pediatric Oral Health and Dentistry, London, ON, Canada
11Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
12Department of Rehabilitation Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
13Division of Endocrinology and Metabolism, and the Institute for Human Genetics, Department of Medicine, University of California, San Francisco, CA, USA
14Royal National Orthopaedic Hospital, Stanmore, UK
15Department of Pediatrics, Klinikum Garmisch-Partenkirchen GmbH, Garmisch- Partenkirchen, Germany
16Department of Internal Medicine section Endocrinology, Amsterdam Bone Center, Amsterdam University Medical Centers, location VUmc, Amsterdam, the etherlands
17Paediatric Rheumatology, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
18Departments of Orthopaedic Surgery and Genetics, The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania; and MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, DC, USA
19Department of Endocrinology, Tongji Hospital, Shanghai Tongji University, Shanghai, China
20Department of Medicine, Mayo Clinic, Rochester, MN, USA
Frederick S. Kaplan, M.D.
Isaac & Rose Nassau Professor of Orthopaedic Molecular Medicine Chief, Division of Orthopaedic Molecular Medicine
Perelman School of Medicine The University of Pennsylvania
c/o Department of Orthopaedic Surgery Penn Musculoskeletal Center - Suite 600 3737 Market Street
Philadelphia, PA 19104
Key Words: fibrodysplasia ossificans progressiva (FOP), heterotopic ossification, ACVR1, BMP pathway signaling, clinical trials
Running Title: Clinical Trials for FOP
Recent developments in clinical trials for fibrodysplasia ossificans progressiva (FOP; MIM # 135100) have left us feeling as if we are in the twilight zone – “that neutral territory somewhere between the real world and fairyland” as the author Nathaniel Hawthorne described [1,2]. On the one hand, we have emerging results from some clinical trials that inspire hope (NCT03312634; NCT03188666) [3, 4]; while on the other hand, the same trials have been paused due to the emergence of serious adverse events or concern for futility [5, 6]. The International Clinical Council on FOP (ICC) has monitored and will continue to monitor these occurrences with vigilance.
This is a critical time to reflect where we have been, where we are now, how we got to where we are now, and where we are going as a community, if indeed we can know. It is not a risk-free journey, and we have been reminded that there are obstacles along the path. But, neither is it a journey devoid of hope; quite the opposite, in fact.
The discovery of the FOP gene heralded the emergence of a new grammar for drug discovery in FOP and the explosion of interest and laser focus of the biopharmaceutical industry on the well-defined and evolutionarily-conserved bone morphogenetic protein (BMP) signaling pathway [7-11]. Like dominoes in descent, the FOP gene discovery enabled the development of genetically correct animal models of FOP – which has been instrumental in testing novel therapeutics for druggable targets [12, 13]. Animal models validated the dysregulated BMP signaling pathway in FOP, the pathophysiology of heterotopic ossification (HO) in FOP, and progenitor cells responsible for HO in FOP
[14-25]. Dramatic basic science discoveries coupled with a comprehensive understanding of the natural history of FOP and methodologies to detect early bone formation further fueled the advent of clinical trials [26-30]. The grammar of investigational drug discovery rapidly became a babble of promising new approaches that were rapidly cast on the stage of human clinical trials – a dazzling place to be for an ultra-rare condition that had existed in the backwaters of medicine for over three centuries and for which no approved treatment and no discernible hope previously existed. But beware of good news. As Shakespeare said, “Roses have thorns and silver fountains mud .”
While dramatic advances showed that the FOP gene discovery could enable identification of druggable targets, it also revealed that drug development would likely be constrained by an ancient and highly-conserved signaling pathway that was redundant and iterative thus making therapeutic specificity difficult [10, 11]. While the desired goal of targeting the dysregulated BMP signaling pathway in FOP is clearly the abrogation of HO, the BMP pathway is critically important in the maintenance and repair of nearly every major organ system, thus expanding the risks of collateral side effects of potentially therapeutic drugs . In addition, there are important logistical considerations and constraints of model systems, not the least of which is that FOP mice are laboratory-raised, pathogen-free genetic clones and are not people with FOP, and thus do not inherently manifest either the immunological vitality or genetic variability that underlies both the range of potential benefits and the range of potential risks that human beings will inevitably display . Thus, while translational studies are essential to enlighten the way forward, they in no way guarantee an unobstructed path.
Potential benefits and inherent risks need to be weighed - not just at the outset but continuously throughout a clinical trial. Aspirational outcomes of successful treatments may vary from one clinical trial to another based on the mechanism of action of the investigational drug and the pre-determined, primary outcome of a clinical trial. Possible long-term benefits of patient involvement in a clinical trial may theoretically include but are not limited to decreased flare-ups, decreased HO, preservation of joint mobility, retardation of joint degeneration, liberation of joints ankylosed with HO, pain relief, frequent medical monitoring, increased self- and FOP-awareness, improved quality of life, a pioneer spirit, contribution to a greater good or contribution to future generations.
Individual participation in a clinical trial must be balanced by a thoughtful consideration of potential benefits and risks. Clinical trials are not proven treatments, but rather an opportunity to determine if a potential therapy is effective and safe. Potential risks may vary from one clinical trial to another. These are assessed based on pre-clinical toxicology studies, phase-1 clinical trial results, or knowledge of the mechanisms of action of an investigational drug. However, these assessed risks may not be comprehensive and new risks may be identified when potential therapies are tested in a clinical trial. Common categories of risk include the inconvenience of participating in a clinical trial – especially during a pandemic, the uncertainty of knowing whether one is initially randomized to a placebo group or a treatment group, the occurrence of annoying or harmful side effects both anticipated and unanticipated, potential allergies to a drug, adverse drug reactions, non-response, resistance to possible therapeutic effects, intolerability of a drug, and worsening of FOP despite pre-clinical data that suggest the therapy in question may be helpful.
Every drug has side-effects, but with investigational drug development for FOP, the spectrum of side-effects may not be fully known until the drug is tested in FOP patients, despite extensive pre-clinical toxicology studies. Even approved and re-purposed drugs may have different side-effects in the FOP population than are seen when the same drug is used in other conditions. Potential risks can often be assuaged, but even with safety nets and firewalls in place, certain risks can elude prompt detection. And then, there are the “unknown unknowns”  – the unanticipated and unpredictable risks that arise out of nowhere and take everyone by surprise. Often these risks are relatively minor, but sometimes – to the consternation of all – they might be harmful or even fatal.
Our early foray into FOP clinical trials reminds us what we knew from the very beginning - that clinical trials are not proven treatments; they are human experiments, guided by the best available knowledge at the time the trial was designed. They have theoretical benefit and palpable risk that are spelled-out in informed consent. Informed consent is not just a quaint formality; it is a solemn requirement and an ongoing process at every step of the clinical trials journey. Further, patient safety is hard-wired into all clinical trials in the form of an independent Data Safety Monitoring Board (DSMB) comprised of 3-6 experts in various disciplines related to the study drug and trial design that monitors occurrences such as unexpected serious adverse events and can pause or stop a trial in its tracks if it detects an unforeseen problem that may be related to an investigational drug. A DSMB can also stop a clinical trial early if the beneficial effects are so overwhelming to suggest that continuation of the trial would not be necessary or if it was determined that the investigational drug is futile. Thus, the DSMB, the sponsor or regulatory authorities for that matter have the jurisdiction to pause or stop a clinical trial for any reason at any time. And, of course, the trial participant has the absolute right to bail-out at any time, for any reason, or for no expressed reason at all. As one sponsor observed, “There is not an endeavor on the planet that is more highly regulated than clinical trials .” Clinical trials are, after all, not proven treatments; not yet at any rate. Some may be. Some may never be. It is worth remembering.
As patients are bombarded by possibilities and choices – by good news and bad – where does that leave them? For the moment – in the twilight zone – somewhere between an old world of symptomatic management and a brave new world of therapeutic possibilities [35-37]. That ultimate gateway is possible only through clinical trials – and patients who embark on that journey are courageous pioneers. Patients and parents must always be aware that there are risks - some known and closely monitored – and some unknown and clearly unexpected – the “unknown unknowns” . So, how should patients proceed? Obviously with caution, but not paralyzed by fear; obviously with hope, but also with respect for the unknown. Novel therapies can emerge only from an FOP community working together. Without clinical trials, there will be no approved treatments and all our efforts will be in vain.
So what is the take-home message? There are two. First, clinical trials are not proven treatments. They have the potential to become treatments if they prove efficacious and safe. They must be both. Each individual (or surrogate) must weigh the potential benefits and risks of enrolling in a clinical trial and decide for themselves if it is right for them - with ongoing informed consent as the guiding light; it is a deeply personal decision. Second, clinical trials are the only path to an approved treatment, and we all have an abiding hope and belief that well-designed and executed clinical trials will be the path that will lead there . We are greatly encouraged that so many pharmaceutical companies are developing novel therapeutics for such a rare and complex disease as FOP - and that they are doing this carefully, responsibly and at great risk to themselves. Side-effects, adverse effects and even unanticipated effects will likely occur. Nobody wants them, but in every case they will be assiduously monitored and immediately investigated by the sponsors and researchers to determine if and how they are related to the investigational drug. And, if and when risks are identified that may be related to the investigational drug, appropriate risk management measures and mitigations will be incorporated into further iterations of the clinical trial to ensure ongoing patient safety. Scientists, doctors, patients, clinical research personnel, pharmaceutical companies and regulatory authorities will continue to work together to make this effort as safe, transparent and successful as possible. This vigilance to safety and transparency on everyone’s part will lead us together through the twilight zone.
In summary, clinical trials are painstaking processes that weigh potential benefits to the patient and society against potential harm to the individual enrolled. Clinical trials are a bold step into the future, along a path like no other - a path that is hopeful, but with obstacles, to be sure. But as someone famously said, “Obstacles along the path are not obstacles – they ARE the path .” That is our hope.
The authors thank the Center for Research in FOP & Related Disorders at the University of Pennsylvania and The Radiant Hope Foundation for supporting the International Clinical Council for FOP (ICC). FSK received support from the Isaac & Rose Nassau Professorship of Orthopaedic Molecular Medicine at the University of Pennsylvania. RJP received support from the Robert and Arlene Kogod Professorship and the Radiant Hope Foundation. MAM received funding from the Ian Cali FOP Clinical Scholarship.
The editorial was conceived by FSK and RJP, written by FSK and revised and approved by all of the authors.
Conflict of Interest Statement
GB, CLDC, PD, EMWE, ECH, NH, FSK, RK, MAM, JCN, RJP, MDR and MAZ receive clinical trials research funding from Ipsen/Clementia Pharmaceuticals. RJD and RM are consultants for Ipsen/Clementia Pharmaceuticals.
MAZ is on the data safety monitoring board for Ipsen/Clementia Pharmaceuticals.
EMWE, ECH, RK, FSK, MAM, RJP and MDR receive clinical trials research funding from Regeneron Pharmaceuticals.
RM is a paid consultant for Regeneron Pharmaceuticals.
GB, CLDC, PD, EMWE, NH, ECH, FSK, RK, RM, JCN, RJP, MDR, CS, MAZ and KZ serve as unpaid volunteers on the IFOPA Medical Registry Advisory Board.
EMWE, ECH, RJP and FSK serve as unpaid volunteers on the FOP Biomarker Consortium.
ECH serves as an unpaid volunteer on the Fibrous Dysplasia Foundation Medical Advisory Board.
MDR is a consultant and/or speaker for Sanofi‐Genzyme, Shire, Alexion, Biomarin, Chiesi, Ipsen/Clementia Pharmaceuticals, and Regeneron Pharmaceuticals and receives clinical trial research support from Sanofi-Genzyme, Alexion and Enzyvant.
AC is a trustee of the Radiant Hope Foundation and trustee of the Ian Cali FOP Research Fund ‐ PENN Medicine ‐ Center for Research in FOP & Related Disorders, and is an unpaid volunteer with Ipsen/Clementia Pharmaceuticals Burden of Illness Advisory Group.
PD is an unpaid medical advisor for FOP Brazil. MAM and MAZ are nonpaid consultants for BioCryst.
EMWE is an advisor for AstraZenica and Ipsen Pharmaceuticals. ECH receives clinical trial support from Neurocrine Biosciences, Inc.
RK receives research support from UltraGenyx; is a paid consultant for Ipsen/Clementia Pharmaceuticals, Regeneron Pharmaceuticals, UltraGenyx, Internis, and Alexion; and is a nonpaid member of the Medical Advisory Board for the UK Brittle Bone Society.
All authors are active members of the International Clinical Council (ICC) on FOP.
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