Teclistamab for ME/CFS

[Utsikt]

And that might show that not everything must be "inherently ok" to be potentially useful.

I'm not advocating for or against the use of teclistamab, I'm just sharing what I heard from the doctor looking into it. I personally believe there is merit in case studies to generate data, if patients are properly informed of the risks and the risks are mitigated as much as possible.

It seems to me like they are just experimenting based on speculations based on questionable hypotheses.

At some point, drug trials might be warranted to test a hypothesis. But there is a lot that needs to happen before that. And the experiments should be done in a way that generates as valuable data as possible.

We see far too many practitioners that run endless case studies instead of doing real trials. Often using excuses like «it’s urgent to get these people some help» or «I’m convinced it works/might work». But if your motivation is to help, how can you know you’re helping if you’re not checking properly using proper trials?

 

[rapidboson]

It seems to me like they are just experimenting based on speculations based on questionable hypotheses.

I don't disagree. They likely are just piggybacking on the Fluge/Mella hypothesis they're using for their phase II. Who knows if they're on the right path. If it's actually a T-Cell mediated disease like JE seems to believe, their hypothesis might not go very far.

At some point, drug trials might be warranted to test a hypothesis. But there is a lot that needs to happen before that. And the experiments should be done in a way that generates as valuable data as possible.

Agree as well. I don't know what data they have, but it's at least not publicly available at this point.

We see far too many practitioners that run endless case studies instead of doing real trials. Often using excuses like «it’s urgent to get these people some help» or «I’m convinced it works/might work». But if your motivation is to help, how can you know you’re helping if you’re not checking properly using proper trials?

Real trials are unfortunately just orders of magnitude more expensive (and struggle to get funding - even with data like Fluge/Mella) and thus may never happen for a certain medication. Hence, I do understand that some case studies are being done (again, if done with information on and mitigation of risks).
Whether a proper trial would be better is surely nothing to discuss, that's obvious.

 

[Jonathan Edwards]

I personally believe there is merit in case studies to generate data, if patients are properly informed of the risks and the risks are mitigated as much as possible.

But in this context case studies do not generate data - at least no positive data of any use to further development.

Moreover, serious adverse reactions (including fatal ones) can occur with monoclonals even with small doses. they tend not to be dose dependent. And small doses may produce an anti-drug response that makes further use ineffective.

Investigating the use of these agents requires a huge amount of care and commitment to useful science rather than clinical income. I do not know all the details but this sounds totally irresponsible.

 

[Utsikt]

Real trials are unfortunately just orders of magnitude more expensive (and struggle to get funding - even with data like Fluge/Mella) and thus may never happen for a certain medication. Hence, I do understand that some case studies are being done (again, if done with information on and mitigation of risks).
Whether a proper trial would be better is surely nothing to discuss, that's obvious.

The fact that trials are harder to do doesn’t justify doing case studies all the time, as these people apparently do. If you don’t have the resources to do it properly, you should just stay out of experimenting altogether, because the patients are the ones that are exposed to all the risks.

 

[rapidboson]

But in this context case studies do not generate data - at least no positive data of any use to further development.

Could you elaborate? As far as I know, I don't know what data they have nor what diagnostics, inclusion criteria etc they use. If done properly, why would it not generate useful data? Genuinely curious.

Moreover, serious adverse reactions (including fatal ones) can occur with monoclonals even with small doses. they tend not to be dose dependent. And small doses may produce an anti-drug response that makes further use ineffective.

Also genuinely curious: how come adverse events tend not to be dose dependent?

How common/how high is the risk of ADAs against human and humanized mAbs?

This is what I could find in a quick online search (didn't read the whole paper, but will):

Although the highly engineered nature of bispecific antibodies can lead to increased risk of immunogenicity, the incidence of anti-drug antibodies (ADAs) following teclistamab was low.5 ADA at low titers were detected at very low frequency (<1%) in the MajesTEC-1 study, and no ADAs were detected in patients treated at the RP2D.6 Although the data were limited, ADAs did not impact the safety or PKs of teclistamab.

Investigating the use of these agents requires a huge amount of care and commitment to useful science rather than clinical income. I do not know all the details but this sounds totally irresponsible.

Neither do I know the details, unfortunately. It's all very speculative. From what I know, this is a public doctor - the only costs are the medication which seems to be under 1000€ for the whole course (as they are using much less than what's used in MM). So not sure whether clinical income is their goal - but also not a clinician so no idea.

The fact that trials are harder to do doesn’t justify doing case studies all the time, as these people apparently do. If you don’t have the resources to do it properly, you should just stay out of experimenting altogether, because the patients are the ones that are exposed to all the risks.

And thus, if you do it, you should be informing about and mitigating risks as much as possible. Which also, I don't know if/how that's happening here. Again, I'm just the messenger.

 

[Jonathan Edwards]

Could you elaborate? As far as I know, I don't know what data they have nor what diagnostics, inclusion criteria etc they use. If done properly, why would it not generate useful data? Genuinely curious.

The first thing you want to know is improvement in the condition but for ME/CFS the measures are so subjective and placebo and relate issues so big that you are not going to get any direct data. There are not going to be any indirect or surrogate data because there are no abnormalities like raised CRP that we know to be surrogates. There are no known relevant autoantibodies so they tell us nothing. So there will be no efficacy data of any use.

I do not see any particular scientific rationale for this particular drug either, so even if the patient is purely being used to generate pharmacodynamic data I don't see that anyone would know how to interpret it.

Also genuinely curious: how come adverse events tend not to be dose dependent?

Adverse effects to drugs are often dose-independent, especially if they are hypersensitivity phenomena. The dose makes no difference.

How common/how high is the risk of ADAs against human and humanized mAbs?

It depends on the competence of the physician. In the hands of a very careful physician serious ADAs like sterile pneumonitis may occur in perhaps 5-10% of cases. Fatal ADAs might be as low as 0.2% but may be closer to 1% in real life cohorts. In the hands of a physician who does not know what they are doing the risk is higher. There were a lot of infective deaths from rituximab when people started using it without knowing what they were doing.

But the ADAs don't get reported in publications. I nearly had to take Roche to court for failing to tell me about the death in my phase 2 multicentre trial, until a junior rep tipped me off. Physicians find it very easy to explain deaths some other way.

the only costs are the medication which seems to be under 1000€ for the whole course (as they are using much less than what's used in MM).

If the dose you mention is right this is totally unjustified. Just exposing people to a level of drug that will have no effect. I may be wrong but that dose sounds like a deliberate confidence trick.

 

[rapidboson]

The first thing you want to know is improvement in the condition but for ME/CFS the measures are so subjective and placebo and relate issues so big that you are not going to get any direct data. There are not going to be any indirect or surrogate data because there are no abnormalities like raised CRP that we know to be surrogates. There are no known relevant autoantibodies so they tell us nothing. So there will be no efficacy data of any use.

I do not see any particular scientific rationale for this particular drug either, so even if the patient is purely being used to generate pharmacodynamic data I don't see that anyone would know how to interpret it.

But the Fluge/Mella pilot study - not Placebo controlled - does seem to have generated enough data to warrant the new phase II RCT, doesn't it? How would this be fundamentally different here, in the most ideal case?

Adverse effects to drugs are often dose-independent, especially if they are hypersensitivity phenomena. The dose makes no difference.

Ah right, I was rather thinking about potential pharmacodynamic mechanisms (like some unknown off-target effects that shouldn't be there) rather than anaphylaxis/hypersensitivity.
If I understand correctly, CRS and ICANS (SAEs of teclistamab) would not be hypersensitivity, would they? If not, would these be expected to be dose-dependent SAEs?

It depends on the competence of the physician. In the hands of a very careful physician serious ADAs like sterile pneumonitis may occur in perhaps 5-10% of cases. Fatal ADAs might be as low as 0.2% but may be closer to 1% in real life cohorts. In the hands of a physician who does not know what they are doing the risk is higher. There were a lot of infective deaths from rituximab when people started using it without knowing what they were doing.

I think I'm misunderstanding something here - aren't ADAs against the drug, rendering it ineffective? Would these ADAs by binding to drug and signalling through FC also be able to cause hypersensitivity reactions that can be fatal to patients, or what's the mechanism of action here?

So 1% of rituximab patients for example die due to ADAs, do I understand this number correctly?

If the dose you mention is right this is totally unjustified. Just exposing people to a level of drug that will have no effect. I may be wrong but that dose sounds like a deliberate confidence trick.

From what I was told in a mail, they've seen low grade CRS after initial dosing (thus pretreatment with prednisolone and paracetamol) and longer term hypogammaglobulinemia - would this not be an indication for efficacy even at these low doses?

 

[Braganca]

They likely are just piggybacking on the Fluge/Mella hypothesis they're using for their phase II.

He is not going off what Fluge and Mella are doing though... He describes his own hypothesis in the video I posted — treating people based on GCPR autoantibodies, and “subsets” or diff levels of these. (edit to add: Also “spike proteins” in WBC and “exosomes”). He also describes using drugs which were trendy amongst shady practitioners during the pandemic.. ivermectin and marivaroc.

 

[rapidboson]

He is not going off what Fluge and Mella are doing though... He describes his own hypothesis in the video I posted — treating people based on GCPR autoantibodies, and “subsets” or diff levels of these. (edit to add: Also “spike proteins” in WBC and “exosomes”). He also describes using drugs which were trendy amongst shady practitioners during the pandemic.. ivermectin and marivaroc.

Most certainly a lot of weird things there! As EndME mentioned earlier in this thread as well.

 

[Jonathan Edwards]

But the Fluge/Mella pilot study - not Placebo controlled - does seem to have generated enough data to warrant the new phase II RCT, doesn't it? How would this be fundamentally different here, in the most ideal case?

I am not sure that study tells us anything about efficacy either. The only thing from that study that makes me think there might be a real effect is the correlation between NK numbers and response. But that is a chance finding that might well mean nothing either. Fluge would probably have done better to go straight to a properly controlled study.

If I understand correctly, CRS and ICANS (SAEs of teclistamab) would not be hypersensitivity, would they? If not, would these be expected to be dose-dependent SAEs?

Abbreviations are bet avoided. By CRS you probably mean cytokine release syndrome. That can be triggered by all sorts of things, including hypersensitivities. I have no idea what ICANS means. Nobody actually knows the mechanism of the commonest major SAE with rituximab (sterile pneumonitis). It may involve immune complex formation in lung but it may be other things. Adverse events with monoclonals often occur with the first dose early on for reasons we don't know.

I think I'm misunderstanding something here - aren't ADAs against the drug, rendering it ineffective? Would these ADAs by binding to drug and signalling through FC also be able to cause hypersensitivity reactions that can be fatal to patients, or what's the mechanism of action here?

I don't follow that.

So 1% of rituximab patients for example die due to ADAs, do I understand this number correctly?

In real life probably yes, because in real life there are lots of people with added risk factors for adverse events, either from severe disease or things not known or inadequately thought about.

From what I was told in a mail, they've seen low grade CRS after initial dosing (thus pretreatment with prednisolone and paracetamol) and longer term hypogammaglobulinemia - would this not be an indication for efficacy even at these low doses?

I would need to see detailed data. The whole thing sounds like a cowboy outfit to me.

 

[rapidboson]

I am not sure that study tells us anything about efficacy either. The only thing from that study that makes me think there might be a real effect is the correlation between NK numbers and response. But that is a chance finding that might well mean nothing either. Fluge would probably have done better to go straight to a properly controlled study.

Understood.

Abbreviations are bet avoided. By CRS you probably mean cytokine release syndrome. That can be triggered by all sorts of things, including hypersensitivities. I have no idea what ICANS means. Nobody actually knows the mechanism of the commonest major SAE with rituximab (sterile pneumonitis). It may involve immune complex formation in lung but it may be other things. Adverse events with monoclonals often occur with the first dose early on for reasons we don't know.

Immune effector cell-associated neurotoxicity syndrome, seemingly one of the SAEs of the drug we're discussing. Surely can also be caused by hypersensitivities?

I don't follow that.

Until now I only thought about ADAs as detrimental to efficacy of the drug, but you're suggesting they can be fatal to the patient as well (due to hypersensitivities?)?

I would need to see detailed data. The whole thing sounds like a cowboy outfit to me.

Agree.

 

[Jonathan Edwards]

Until now I only thought about ADAs as detrimental to efficacy of the drug, but you're suggesting they can be fatal to the patient as well (due to hypersensitivities?)?

I think I thought you meant Adverse Drug Actions. Abbreviations are a nightmare.
But anti-drug antibodies can kill you, yes.

 

[rapidboson]

I think I thought you meant Adverse Drug Actions. Abbreviations are a nightmare.

Oh, I thought my previous quoted text that defined ADAs as anti-drug antibodies was clear. And you were talking about the anti-drug response.

But anti-drug antibodies can kill you, yes.

I take, your previous posts though, quoting the 1% fatality, are regarding adverse effects and not anti-drug antibodies? That number sounds quite high to me, if you're talking about anti-drug antibodies.
How common is death through anti-drug antibodies?

 

[Jonathan Edwards]

How common is death through anti-drug antibodies?

We don't know because in most cases we do not know the mechanism. I suspect anti-drug antibody is often involved in deaths.

 

[someUsername]

I think its pretty cool what he is doing.
And in light of the weird funding studys get totally reasonable. We are gazing about uncontrolled N=10 trials from norway. Noone is ever going to be sure about Ritux because they Had to lower the dosage because of funding.
This is insane, and in this Environment there are a Lot of patients whos individual cost functions are such that it makes sense for them to experiment;
and on top of that, we are still in a Situation where annecdotal Data is actually usefull. Sadly so.
I understand ethical concerns, but we do Not need to be "päpstlicher als der Papst".

 

[Utsikt]

I think its pretty cool what he is doing.

I don’t think it’s cool to expose people to the risk of death in return for useless data.

And in light of the weird funding studys get totally reasonable.

No, it’s not. The reasonable thing would be to not do it.

We are gazing about uncontrolled N=10 trials from norway.

I’ve not seen anyone here go crazy over it. There’s been criticism of the lack of placebo and blinding, and people are cautious about becoming optimistic due to large placebo effects from saline in the ritux trials.

Noone is ever going to be sure about Ritux because they Had to lower the dosage because of funding.

Where did you get that info from?

 

[V.R.T.]

Where did you ge

Mella said so in his Charite talk this year.

 

[someUsername]

Do you have any links to studies?

We don’t know if Dara or Tecil works for ME/CFS.

Yeah sorry, Not Sure why I wrote it this way. What I meant is that assumimg dara works there seems to be some sort of Connection between dara and Tecil, so that it is Not complety Out of the blue that Habs is trying Tecil. But yes we do not even know If Dara works.


This is the ongoing Phase 3:

https://ascopubs.org/doi/10.1200/JCO.2022.40.16_suppl.TPS8072

And this Phase 2:

https://ascopubs.org/doi/10.1200/JCO.2022.40.16_suppl.8032

 

[someUsername]

I don’t think it’s cool to expose people to the risk of death in return for useless data.

Data is Not entirly useless.

No, it’s not. The reasonable thing would be to not do it.

You do not know the individual cost functions of people, I think its unreasonable to assume that Out of all patients, there are Not some for whom It makes sense.

I’ve not seen anyone here go crazy over it. There’s been criticism of the lack of placebo and blinding, and people are cautious about becoming optimistic due to large placebo effects from saline in the ritux trials.

Yes, not here, but Its still making quite a wave right ?

Where did you get that info from?

Scheibenbogen hypothized this,
and the group in Japan who are now trying Ritux again (idk why?) also do not seem entirly convinced about that Trial. I also think its unlikely that Ritux works, but the point beeing: Its insane to introduce so much uncertanty in the results just because you do not get funding for the same Dosis as in the Phase 1 Trial.

 

[V.R.T.]

Fluge would probably have done better to go straight to a properly controlled study

Agreed. Hopefully if any theraputic experiments follow on from DecodeME they will include controls from the get go.