Leary, Eileen

Abstract Introduction AXS-12 (reboxetine) is a highly selective norepinephrine reuptake inhibitor and cortical dopamine modulator under development for narcolepsy. In the Phase 3 SYMPHONY trial, AXS-12 significantly reduced weekly cataplexy attacks from baseline to Week 5 versus placebo in patients with narcolepsy. Here we report the Phase 3 ENCORE trial, assessing long-term efficacy and safety of AXS-12 in participants who completed SYMPHONY. Methods ENCORE included a 24-week open-label extension (OLE) period, followed by a 3-week double-blind randomized-withdrawal (DBRW) period. During the OLE, participants received AXS-12 (5 mg once-daily for 1 week, twice-daily for 23 weeks). Following this, remaining participants were randomized 1:1 to continue twice-daily AXS-12 or switch to once-daily AXS-12 plus placebo for 1 week, then placebo twice-daily for 2 weeks. The primary endpoint was change in frequency of cataplexy attacks from randomization to DBRW Week 3. OLE efficacy outcomes included change in weekly frequency of cataplexy attacks, cataplexy response (≥50% reduction), and change in cataplexy-free days. Additional analyses are ongoing. Results ENCORE enrolled 68 participants; 42 completed the OLE and entered the DBRW (AXS-12, n=22; placebo, n=20). In SYMPHONY, baseline mean weekly frequency of cataplexy attacks was 31.5. At DBRW randomization, mean weekly frequency of cataplexy attacks was 4.2 (AXS-12) and 6.9 (placebo). Participants randomized to placebo experienced a mean increase of 10.29 weekly cataplexy attacks versus 1.32 for AXS-12, at end of DBRW (p=0.017). In the OLE, weekly frequency of cataplexy attacks decreased by 22.3 (71%) and 24.1 (77%) at 1 and 6 months, respectively. Cataplexy response was achieved by 72% and 82% at 1 and 6 months, respectively. Cataplexy-free days increased from 14.3% to 61% and 70% at 1 and 6 months, respectively. Common adverse events (AEs; ≥5%) during the OLE were nausea and tachycardia (both 5.9%); no new safety signals were detected. Discontinuations due to AEs occurred in 17.6% of participants in the OLE. Conclusion AXS-12 significantly reduced the frequency of cataplexy attacks during the DBRW. AXS-12 was well-tolerated and demonstrated maintenance of efficacy with long-term open-label use. These results align with SYMPHONY, supporting the positive therapeutic impact of AXS-12 for narcolepsy. Support (if any) Axsome Therapeutics, Inc.

Abstract Introduction Narcolepsy is a chronic neurologic condition associated with severe symptom burden, impaired functioning and reduced quality of life. Patients commonly report comorbid mood disorders. AXS-12 (reboxetine) is a selective norepinephrine reuptake inhibitor and cortical dopamine modulator under investigation for the treatment of narcolepsy. In the Phase 3 SYMPHONY trial, AXS-12 met the primary endpoint, a statistically significant reduction in weekly cataplexy attacks from baseline to Week 5 versus placebo. Here, we report secondary endpoints assessing symptom severity, daily functioning, and mood. Methods SYMPHONY was a randomized, double-blind, placebo-controlled trial in patients with narcolepsy type 1 (NT1). Participants (15-75 years) were randomized 1:1 to AXS-12 or placebo for 5 weeks. Stable, concurrent modafinil/armodafinil use was allowed. Secondary endpoints included: the Clinical Global Impression of Severity (CGI-S) for narcolepsy, the Functional Outcomes of Sleep Questionnaire short version (FOSQ-10), and the EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaire anxiety/depression domain. Results Ninety participants were enrolled. At baseline, mean (SD) CGI-S for narcolepsy score was 5.2 (1.0) in the AXS-12 arm and 4.9 (1.0) in the placebo arm. AXS-12 led to a significant reduction versus placebo in CGI-S for narcolepsy at Week 5 (LS mean difference [95% CI]=0.72 [0.29, 1.16]; p=0.001). At baseline, mean FOSQ-10 total score was 11.1 (3.1) in the AXS-12 arm and 11.6 (3.2) in the placebo arm. AXS-12 led to a statistically significant improvement from baseline to Week 5 in FOSQ-10 total scores compared to placebo (1.66 [0.51, 2.82], p=0.005). At baseline, 47.8% of participants in the AXS-12 arm and 45.5% in the placebo arm reported anxiety/depression (EQ-5D-5L). A numerically greater proportion of participants achieved improvements on this domain with AXS-12 (55.0%) versus placebo (31.6%) at Week 5 (p=0.146). Conclusion AXS-12 demonstrated significant reductions in clinical impressions of narcolepsy symptom severity. Functional impairment due to EDS was also significantly reduced, in-line with previously reported improvement in clinician-rated assessments. Anxiety and depression-related symptoms showed trends favoring AXS-12. Combined with prior findings on cataplexy and cognitive improvements, these results highlight the potential of AXS-12 as a therapeutic option addressing multiple symptoms of narcolepsy which affect QoL and functioning. Support (if any) Axsome Therapeutics, Inc.

Obstructive sleep apnea (OSA), a disease associated with excessive sleepiness and increased cardiovascular risk, affects an estimated 1 billion people worldwide. The present study examined proteomic biomarkers indicative of presence, severity, and treatment response in OSA. Participants (n = 1391) of the Stanford Technology Analytics and Genomics in Sleep study had blood collected and completed an overnight polysomnography for scoring the apnea–hypopnea index (AHI). A highly multiplexed aptamer-based array (SomaScan) was used to quantify 5000 proteins in all plasma samples. Two separate intervention-based cohorts with sleep apnea (n = 41) provided samples pre- and post-continuous/positive airway pressure (CPAP/PAP). Multivariate analyses identified 84 proteins (47 positively, 37 negatively) associated with AHI after correction for multiple testing. Of the top 15 features from a machine learning classifier for AHI ≥ 15 vs. AHI < 15 (Area Under the Curve (AUC) = 0.74), 8 were significant markers of both AHI and OSA from multivariate analyses. Exploration of pre- and post-intervention analysis identified 5 of the 84 proteins to be significantly decreased following CPAP/PAP treatment, with pathways involving endothelial function, blood coagulation, and inflammatory response. The present study identified PAI-1, tPA, and sE-Selectin as key biomarkers and suggests that endothelial dysfunction and increased coagulopathy are important consequences of OSA, which may explain the association with cardiovascular disease and stroke.

Abstract Introduction Obstructive sleep apnea (OSA) is characterized by recurrent, partial or complete obstructive respiratory events accompanied by interruptions in sleep with frequent arousals, deoxygenation, and/or sleep disturbance. The present study profiled the largest array of plasma proteins, to date, to contribute to the identification of proteomic biomarkers associated with the presence and severity of OSA. Methods The SomaScan highly multiplexed aptamer assay was used to profile 5,000 proteins in 24–48-hour old EDTA plasma samples from the Stanford Technology Analytics and Genomics in Sleep (STAGES) study. The apnea-hypopnea index (AHI) was derived from overnight polysomnography and all participants provided a blood sample. OSA severity was classified as moderate-to-severe (AHI&gt;15) and controls/mild OSA (AHI&lt;15). Univariate linear regression analyses included log2-normalized relative protein expression as the dependent variable, AHI/OSA as the independent variable, and important covariates such as age, gender, BMI, BMI2, age x gender x BMI, sample storage time, and blood draw period. False discovery rate (FDR) to control for multiple testing was applied with an a-priori p-value of 0.05 for identifying significance. Results Univariate analyses identified 101 (65 upregulated, 36 downregulated) differentially expressed proteins (DEPs) between moderate-to-severe OSA and controls/mild OSA and 120 proteins (69 positive, 51 negative) associated with AHI as a continuous outcome with 70 proteins consistent in both models. Upregulated proteins involved pathways related to complement and coagulation cascades and metabolic processes and downregulated proteins involved pathways related to regulation of insulin-like growth factor, fibrin clot formation, and MAPK signaling. An OSA machine learning classifier (AHI&gt;15 vs AHI&lt;15) trained on relative protein expression performed robustly, achieving 72% accuracy in a validation dataset. Significant contributing features of the classifier included age, BMI, and 134 proteins, including 22 DEPs identified in univariate analyses for OSA categories. Conclusion The present study identified differential protein expression patters associated with OSA and AHI, thereby supporting the potential of proteomic biomarkers in OSA and providing new insight into the mechanisms underlying OSA. Support (If Any) This work was supported, in part, by the National Heart, lung, and Blood institute [T32HL110952] and the Klarman Family Foundation.

Abstract Introduction Periodic limb movements (PLMs) are episodes of involuntary, repetitive muscle movements that are highly associated with restless legs syndrome (RLS). Although PLMs and RLS are reportedly two separate phenomena, both are tightly correlated and may result from a similar pathology. The present study profiled plasma protein biomarkers of PLMs and RLS to contribute to the identification of mechanisms associated with each disorder/trait. Methods The SomaScan highly multiplexed aptamer assay was used to profile 5,000 proteins in 24–48-hour old EDTA plasma samples from the Stanford Technology Analytics and Genomics in Sleep (STAGES) study. PLMs per hour (PLMI) were derived from overnight polysomnography and RLS was classified based on affirmative responses to questions of the Alliance Sleep Questionnaire. Three linear regression models were conducted to examine significant protein markers of 1) PLMI in the sample as a whole; 2) PLMI controlling for the presence of RLS; and 3) RLS without PLMs (i.e.,PLMI&lt;5). All models included log2-normalized relative protein expression as the dependent variable and important covariates such as age, gender, BMI, sample storage time, and blood draw period. False discovery rate (FDR) to control for multiple testing was applied with an a-priori p-value of 0.05 for identifying significant associations. Results PLMI was significantly associated with 253 proteins (219 positive,34 negative). The inclusion of RLS in the model mitigated the significance of most proteins, and only 8 proteins remained significant. Negatively associated proteins (LEAP-1, Ferritin, SELH, Caspase-8) included functions related to iron storage, absorption, and delivery and negative regulation of inflammatory/immune responses. Positively associated proteins (SFRP4, RANTES, CathepsinA, DKK1) included proteins with functions related to immune response, inflammatory response, bone formation, and protein stability. RLS without PLMs was associated with 7 upregulated proteins (megalin, RUFY1, TADBP, ANGL7, LRTM2, SNAPN, STOM) with functions related to vitamin D metabolism, calcium and zinc binding, circadian rhythm regulation, and calcium-dependent neurotransmitter secretion. Conclusion These large proteomic analyses identified independent differential protein expressions for PLMs and RLS that suggest different pathophysiological contributions. Support (If Any) This work was supported, in part, by the National Heart, lung, and Blood institute [T32HL110952] and the Klarman Family Foundation.