Neurology Takes a Page Out of the Oncology Playbook of FDA Accelerated Approvals

The field of neurology is experiencing a significant upswing in innovative therapeutic development, propelled by advances in genetics, neuroimaging techniques, and biomarker research. However, neurological diseases are inherently difficult to treat, and there remains an urgent need to rapidly translate these advances into more effective treatments. It is timely then, that several recent drug approvals in neurology have benefited from FDA’s Accelerated Approval pathway— designed to expedite access to promising drugs to treat serious, life-threatening conditions with a high unmet medical need—a regulatory path most often traveled by oncology drugs.

Four recent accelerated approvals—2 for amyotrophic lateral sclerosis (ALS) and 2 for Alzheimer’s disease—appear to support a shifting regulatory approach to neurological drugs by the FDA, particularly in its willingness to deploy regulatory flexibility.

The ALS Treatment Landscape is Evolving Rapidly

On April 25, 2023, the FDA granted accelerated approval to Biogen’s Qalsody™ (tofersen), indicated to treat a rare, genetic form of ALS mediated by the superoxide dismutase 1 (SOD1) gene, referred to as SOD1-ALS. The approval was based on evidence that tofersen significantly reduced neurofilament light chain (NfL)—a marker of axonal degeneration that is elevated in the blood of many neurologic and neurodegenerative conditions—which correlated with a delay in disease progression and death. Although a failed clinical trial proved a barrier to full approval, the Peripheral and Central Nervous System Drugs Advisory Committee reviewed the data on March 22, 2023, and voted in favor of NfL’s utility as a surrogate endpoint supporting conditional approval. This marks the first instance of a blood biomarker being effectively used as a surrogate endpoint to secure accelerated approval for a neurology drug and underlines the potential benefits of incorporating NfL—and other blood biomarker measurements—into other neurology trial designs.

The FDA’s review of Amylyx’s Relyvrio™ (AMX0035)—a fixed-dose combination of sodium phenylbutyrate plus taurursodiol—was a closely watched regulatory event last year. Marginal efficacy in a phase 2 trial initially prompted the FDA to call for more data; however, they ultimately decided to review the application. Two advisory committee meetings were convened in 2022 and reached opposing outcomes. Panelists on the Peripheral and Central Nervous System Drugs Advisory Committee (PCNS) voted in favor of approving Relyvrio™, just months after voting against the drug. The committee appeared to be swayed by additional analyses of survival benefit, a more acute focus on the unmet need, the FDAs own emphasis on exercising regulatory flexibility, and the sponsors statement that it would withdraw their drug if their phase 3 confirmatory trial fails. Subsequently, the FDA granted accelerated approval of Relyvrio™ for the treatment of ALS in September 2022.

A review in JAMA of oncologic drugs approved between 2000 and 2016 revealed that oncology drugs granted accelerated approval demonstrated a median overall survival (OS) benefit of 2.4 months1. Comparing this to Amylyx’s Relyvrio, which exhibited a 4.8-month median OS benefit, illustrates both a heightened standard of approval for neurologic drugs by the FDA and its advisory committees, and a gulf in the perception of meaningful clinical benefit in the fields of oncology and neurology. Patients and caregivers will argue that the benefit of adding a few months—and vital quality-of-life improvements—to the 3- to-5-year life expectancy of a patient suffering from ALS is just as clinically meaningful as in advanced cancers.

Alzheimer’s Accelerated Approvals Signal Renewed Scrutiny of Surrogate Endpoints

One key factor contributing to the success of accelerated approvals in oncology is the use of surrogate endpoints. These are indirect measures of clinical benefit that can be assessed more quickly than traditional endpoints, like overall survival, and are reasonably likely to predict clinical benefit.

The utility of amyloid-beta protein buildup in the brain (assessed by brain imaging) as a surrogate endpoint believed to be correlated with cognitive decline in Alzheimer’s disease was greenlighted with the approval of Biogen’s Aduhelm™ (adacanumab) in June 2021—the first accelerated approval of an Alzheimer’s drug.

The FDA’s recent willingness to apply regulatory flexibility when reviewing neurology applications, as in the case of Qalsody and Aduhelm—and subsequently approve these drugs under the Accelerated Approval pathway, has resulted in a shift in the regulatory strategy being employed by sponsors. The strategy to utilize the Accelerated Approval pathway in neurology drug development programs may, in part, be driven by (1) the evolution of imaging and biomarkers that can potentially be used as surrogate endpoints, and (2) the openness of FDA to accept those surrogate endpoints.

While the use of the expedited pathway and the decision to use amyloid-beta as a surrogate endpoint reasonably likely to predict clinical benefit was surprising in the case of adacanumab, it has changed the regulatory landscape in neurology by setting precedent. Eisai and Biogen subsequently capitalized on that precedent by picking up another accelerated approval for Leqembi™ (lecanemab) for Alzheimer’s disease, and on June 9th the PCNS voted unanimously for full approval of Leqembi, based on results of the confirmatory trial.

It appears that the regulatory environment surrounding the amyloid-beta class of treatments for Alzheimer’s disease—primed by Aduhelm and Leqembi—continues to bear more fruit. In Eli Lilly’s May 3 press release, we saw the most encouraging results yet for a drug that targets amyloid beta. In a phase 3 trial of more than 1,000 people with early signs of Alzheimer’s disease, donanemab treatment resulted in a slowing of cognitive decline by 35% compared to placebo. It also resulted in 40% less decline in the ability to perform activities of daily living.

Interestingly in that trial, biomarkers were used in a relatively dynamic manner. Firstly, patients were prescreened using a predictive biomarker—plasma p-tau-181—thought to select for patients with both amyloid and tau tangle pathology (the 2 prominent pathologies in Alzheimer’s disease). Subsequently, the data revealed that those who start the trial with fewer tau tangles benefitted the most from donanemab. Incidentally, donanemab slowed (but did not stop) tangle growth, underscoring the benefit of treating earlier in the course of disease.

Secondly, the amyloid beta surrogate biomarker was used to inform clinicians on when to complete patients’ course of treatment with donanemab—by reaching a threshold of amyloid plaque clearance—a strategy that has not been employed in other Alzheimer’s disease trials testing antibodies against amyloid beta.

The National Academies of Sciences, Engineering, and Medicine (NASEM) convened a workshop in January 2023 to examine the FDA’s use of the Accelerated Approval program. There was renewed criticism of the FDAs approval of Aduhelm and a call to increase the transparency around FDA decision-making and its stance on surrogate endpoints. According to Peter Stein, director of the FDA’s Office of New Drugs, “We don’t have a simple formula or algorithm for evaluation of a potential surrogate for accelerated approval.” He went on to emphasize the limitations of using a correlation between the surrogate and established clinical outcomes that demonstrate clinical benefit.

There is clearly a need for a set of transparent standards for the utility of surrogate endpoints, both in therapeutic areas where accelerated approvals have traditionally been applied (oncology and HIV/AIDS) and in neurology. FDA guidance on surrogate endpoints is being developed. Under the Food and Drug Omnibus Reform Act of 2022 (FDORA), the FDA must issue 4 guidance documents related to accelerated approvals within 18 months of FDORA being enacted in December 2022; 2 of which will address surrogate endpoints.

As a wave of innovation continues to crash on the shores of neurological research, the interplay between novel therapeutics, surrogate endpoints, and regulatory flexibility has brought about tremendous progress in the field of neurodegenerative diseases. The FDA’s updated guidance on surrogate endpoints is likely to further accelerate the development of novel treatments based on the best available science.


  1. Ladanie A, Schmitt AM, Speich B, et al. Clinical trial evidence supporting US Food and Drug Administration approval of novel cancer therapies between 2000 and 2016. JAMA Netw Open. 2020;3(11):e2024406. doi: 10.1001/jamanetworkopen.2020.24406.

Muzamil Saleem, PhD
Associate Scientific Director, ProEd Regulatory
Muz is a trained neuroscientist with a diverse skillset, combining a 10-year neurology-focused research career, scientific consulting experience, and a 3-year tenure in healthcare equity research on Wall Street before joining ProEd Regulatory—all supported by a passion for written and visual scientific communication. Connect with Muz on LinkedIn.

Thinking Outside the Beta-Amyloid Box

The dominant amyloid hypothesis of AD has translated into an armada of anti-amyloid biologics in the near-term pipeline—led by Eisai and Biogen’s lecanemab. Last month, lecanemab showed a slowing in the rate of cognitive decline by 27% over 18 months versus placebo. Lecanemab also possesses a relatively improved safety profile among the beta-amyloid mAbs, as a result of lower rates of amyloid-related imaging abnormalities (ARIA) (this was a significant issue with aducanumab). This improved safety profile eliminates the need for a dose titration period. The other notable beta-amyloid mAb drug contenders include Roche’s gantenerumab and Eli Lilly’s donanemab, which may achieve the fastest amyloid plaque clearance among its competitors.

These recent successes, however, come after an approximate 98% failure rate in phase 2 and 3 trials since 2003.1 For a disease that kills more people than breast cancer and prostate cancer combined,2 a modest improvement in cognitive decline is not enough. This has led many labs to pursue other potential targets in AD, with some encouraging early signals of success (Table 1).3

Table 1. Alzheimer’s drug development pipeline: disease-modifying drug candidates with non-amyloid mechanisms of action with corporate sponsor in phase 2 and 3 and select phase 1 drug candidates, grouped by target. Source: Cummings et al (2022).3

SponsorDrug candidateTargetTrial status
Vigil NeuroVGL101TREM2Phase 1
Denali Therapeutics Inc.DNL919TREM2Phase 1
TauRx TherapeuticsTRx0237TauPhase 3; active
AC Immune, JanssenACI-35TauPhase 2; recruiting
UCB BiopharmaBepranemabTauPhase 2; recruiting
EisaiE2814TauPhase 2; recruiting
Ionis PharmaceuticalsIONIS MAPTRx (BIIB080)TauPhase 2; active
JanssenJNJ-63733657TauPhase 2; recruiting
Eli LillyLY3372689TauPhase 2; recruiting
Samus TherapeuticsPU-ADTauPhase 2; active
GenentechSemorinemab (R07105705)TauPhase 2; active
AgeneBio, NIAAGB101Synaptic plasticityPhase 3; active
CortexymeAtuzaginstat (COR388)Synaptic plasticityPhase 3; active
Anavex Life SciencesBlarcamesine (ANAVEX2-73Synaptic plasticityPhase 3; active
Cassava SciencesSimufilam (PTI-125)Synaptic plasticityPhase 3; recruiting
Tetra Discovery PartnersBPN14770Synaptic plasticityPhase 2; active
Neurotrope Bioscience, NIH, NIABryostatin 1Synaptic plasticityPhase 2; recruiting
Cyclerion TherapeuticsCY6463Synaptic plasticityPhase 2; recruiting
Toyama ChemicalEdonerpic (T-817MA)Synaptic plasticityPhase 2; active
Cognition TherapeuticsElayta (CT1812)Synaptic plasticityPhase 2; recruiting
Athira PharmaFosgonimeton
Synaptic plasticityPhase 2; recruiting
Neurokine Therapeutics, et al.MW150Synaptic plasticityPhase 2
EIP PharmaNeflamapimod
Synaptic plasticityPhase 2; recruiting
Biohaven Pharma, ADCSTroriluzole
Synaptic plasticityPhase 2; active
KeifeRxNilotinib BEProteostasis/ proteinopathiesPhase 3
QR Pharma, ADCSPosiphenProteostasis/ proteinopathies
NeurogenesisPhase 2; recruiting
Novo NordiskSemaglutinideMetabolism and bioenergeticsPhase 3; recruiting
CerecinTricaprilinMetabolism and bioenergeticsPhase 3
T3D Therapeutics, et al.T3D-959Metabolism and bioenergeticsPhase 2; recruiting
NewAmsterdam PharmaObicetrapibLipids and lipoprotein receptorsPhase 2
NeurmedixNE3107InflammationPhase 3; recruiting
Alector, AbbVieAL002InflammationPhase 2; recruiting
NovartisCanakinumabInflammationPhase 2; recruiting
GMP BIO, BHT Lifescience AustraliaGB301InflammationPhase 2
IntelGenx Corp.MontelukastInflammationPhase 2; recruiting
Vaccinex, ADDF, Alzheimer’s AssociationPepinemab (VX15)InflammationPhase 2; recruiting
TrueBinding, IncTB006InflammationPhase 2; recruiting
Mindful Diagnostics and TherapeuticsTdap vaccineInflammationPhase 2
Northwell Health, JanssenDaratumumabInflammationPhase 2; recruiting
Shanghai Green ValleyGV-971Gut-brain axisPhase 3; recruiting
Actinogen MedicalXanamemGrowth factors and hormonesPhase 2; active
GemVax & KaelGV1001EpigeneticPhase 2
Neuroscience Trials AustraliaDeferiproneCell deathPhase 2; active

The AD therapeutic landscape appears to be shifting away from symptomatic drugs and focusing more on disease-modifying drugs (DMDs)—a report by the Alzheimer’s Association (AA) showed that 68% of agents in phase 3 trials are DMDs (Figure 2).3 Most of these DMDs target beta-amyloid (29%); however, the remainder represent innovative new directions in targeting the multifactorial, complex pathology of AD.

Figure 2. Mechanisms of action of agents in phase 3.3

The discovery that mutations in “triggering receptor expressed on myeloid cells 2” (TREM2) can increase the risk of AD by up to threefold, suggested the involvement of inflammatory pathology in AD.4-6 TREM2 is a transmembrane protein located on the surface of microglia, the resident immune cells of the brain. Microglia are dynamic, innate immune cells of the brain: functioning to constantly sense extracellular cues (e.g., cellular debris, invading viruses or bacteria) in the central nervous system (CNS). In the absence of extracellular cues, the microglia are in a homeostatic conformation. When cellular debris binds to TREM2, homeostatic microglia are activated and transition to disease-associated microglia (DAM). Microglia in the DAM state also function to clear proteins that aggregate in neurodegenerative diseases—such as amyloid plaques in AD. Because TREM2 loss-of-function mutations are associated with the inability of microglia to transition to the DAM phenotype, they are a rational target in AD. Dysfunctional microglia expressing mutated TREM2 are unable to clear cellular debris, and this leads to a perpetuation of neuroinflammation and subsequent neurodegeneration.

Further research bridging pathologies has revealed that TREM2 biology directly involves beta‑amyloid: TREM2 binds to beta-amyloid, and this binding is compromised in the presence of AD‑associated mutations.7 Moreover, TREM2 has been linked to the long-established genetic risk factor of the late-onset (after age 60) form of AD: the ε4 allele of apolipoprotein E (APOE).8

Targeting TREM2 is particularly attractive because it is restricted to the area of pathology—the brain. Denali Therapeutics’ TREM2-targeted therapy, DNL919, uses a proprietary antibody delivery technology to deliver drug across the protective blood-brain barrier and activate the receptor. DNL919 was this year placed on a clinical hold before it entered human trials due to issues surrounding the preclinical toxicology assessment. Denali is working to provide the FDA with the information needed to restart the clinical trial.

Massachusetts-based Vigil Neuro is developing disease-modifying therapeutics to restore the microglia DAM phenotype by activating TREM2 signaling in order to treat neurodegenerative diseases such as AD. Vigil is targeting the activation of TREM2 with VGL101, a drug currently in a phase 1 healthy volunteer trial that is slated to read out by the end of the year.

The potential role of gut microbiota in AD pathogenesis9 has culminated in the discovery of a plant-based compound, sodium oligomannate (GV-971), by Shanghai Green Valley Pharmaceutical. GV-971 contains an active ingredient derived from brown algae and was recently shown to therapeutically remodel gut microbiota, resulting in the suppression of inflammation and inhibition of AD progression10. China’s drug regulator approved marketing of GV-971 following encouraging results from a 36-week phase 3, multicenter, randomized, double-blind, placebo-controlled parallel-group clinical that revealed significant improvements in cognition.

Deficits in axonal transport—a cellular process that mediates the movement of diverse cargoes along axons—has been shown to be a contributing pathology in the neurodegeneration seen in AD (as well as other neurological diseases).11,12 Buntanetap, a drug being developed by Annovis Bio, inhibits multiple neurotoxic aggregating proteins—including beta-amyloid, tau, α-synuclein and TAR DNA-binding protein 43 (TDP-43)—to restore axonal transport to normal levels. Annovis recently reported positive safety data and a statistically significant improvement in cognition from its phase 2a Alzheimer’s study, and this month received FDA authorization to initiate a phase 2/3 clinical trial of buntanetap in moderate AD.

It appears that the AD field is now refocusing on pathologies outside of aberrant amyloid and tau protein, and looking more closely at diverse biological processes including inflammatory cascades, gut-brain signaling, and axonal transport. It’s likely that ongoing translational research will eventually lead to a better understanding of these diverse pathologies and that overall treatment of AD will ultimately be multifactorial.

Muzamil Saleem, PhD
Associate Scientific Director, ProEd Regulatory
Muz is a trained neuroscientist with a diverse skillset, combining a ten-year neurology-focused research career, scientific consulting experience and a three-year tenure in healthcare equity research on Wall Street before joining ProEd Regulatory—all supported by a passion for written and visual scientific communication. Connect with Muz on LinkedIn.


  1. Kim CK, Lee YR, Ong L, Gold M, Kalali A, Sarkar J. Alzheimer’s Disease: Key Insights from Two Decades of Clinical Trial Failures. J Alzheimers Dis. 2022;87(1):83-100.
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The Alzheimer’s Conundrum

The United States is facing an avalanche of Alzheimer’s disease (AD). An estimated 12.7 million Americans over the age of 65 are projected to suffer from AD dementia by 2050,1 and yet, despite more than 30 years of intensive research, we have yet to develop a drug that provides a clinically meaningful slowing in cognitive decline. There are only 6 AD drugs currently approved in the US. Five of these are symptomatic treatments, such acetylcholinesterase drugs for mild AD and the N-methyl-D-aspartate (NMDA) receptor antagonist memantine, which is used as an add-on or second-line therapy in more severe cases. Aduhelm, a beta-amyloid monoclonal antibody (mAb) therapy, represented the sixth US Food and Drug Administration (FDA) approval in AD and is the first to target the underlying pathology of the disease. However, the beta-amyloid mAbs have failed to live up to the promise of delivering a curative, disease-modifying drug (DMD). We examine directions in research and development that contribute a set of diverse pathological targets—illuminating Alzheimer’s disease as a conundrum that will likely be solved with a multifactorial treatment approach.

The Alzheimer’s Conundrum

So, why have effective AD therapeutics been so elusive? A key factor is the cavernous deficiency in our pathologic understanding of AD. In the amyloid hypothesis, plaques composed of toxic beta-amyloid and phosphorylated tau protein are hypothesized to cause neurodegeneration leading to cognitive decline. This hypothesis has dominated the last 20 years of AD research and carries with it a storm of controversy, to the extent that two camps have formed (those who support the amyloid hypothesis, and those who don’t). At issue is the failure of a long line of drugs targeting beta-amyloid in clinical trials dating back to 2003. Interviews with multiple scientists suggest that any research that fell outside of the amyloid field was suppressed,2 likely slowing progress in the field. In addition, the dire unmet need for AD therapeutics has put a strain on translational research, such that biotech companies have scrambled to move drugs into clinical trials, perhaps before the science was fully baked.

The pathology of AD, best represented as a continuum (Figure 1),1 presents another challenge. Researchers and clinicians believe that therapeutic intervention stands the best chance of success in patients with mild cognitive impairment, but without a reliable biomarker, it can be challenging to identify an appropriate patient population for clinical studies.

Figure 1. Alzheimer’s disease continuum.

The pathological changes in the brain that cause the first noticeable symptoms of AD—related to memory, language, and cognition—are thought to start 2 decades or more prior.3-10 During this asymptomatic phase there may be measurable changes in a biomarker that could indicate future progression to clinical AD. Hence, there is a crucial need for a biomarker sensitive enough to detect AD in early stages. To date, the best available biomarker of AD is the assessment of abnormal beta-amyloid deposits in the brain by positron emission tomography (PET) imaging.

The Lumipulse® beta-amyloid test (Fujirebio Diagnostics) was FDA approved earlier this year and could potentially substitute for the use of PET scans to detect amyloid pathology; however, the test requires collection of cerebrospinal fluid (CSF), which is an unpleasant procedure. The search for a minimally invasive, blood-based biomarker has been at the center of a fervent research effort over the past decade.11 The PrecivityAD® is a blood test developed by C2N Diagnostics that has been shown to be 81% accurate in predicting the level of beta-amyloid in the brain; however, it is not yet FDA approved.

The First Drug to Address the Underlying Biology of Alzheimer’s Disease

The accelerated approval of aducanumab (Aduhelm™), an antibody that binds to and clears beta-amyloid plaques in the brain, in 2020 was a landmark in the treatment of AD, signaling the first new drug in 18 years. Aduhelm was studied in two large, randomized, controlled trials in patients with mild cognitive impairment and evidence of amyloid pathology by PET imaging. However, both trials were prematurely stopped for futility. The first trial (EMERGE) ultimately met its primary endpoint—patients on high-dose aducanumab showed a significant slowing of cognitive decline from baseline. The second trial (ENGAGE) did not meet its primary endpoint; however, patients from this trial who received sufficient exposure to high-dose aducanumab showed efficacy results supporting the findings of EMERGE. Both trials also showed a statistically significant, dose-dependent decrease in beta-amyloid and phosphorylated tau protein by PET imaging, which was the basis for accelerated approval.

Controversy ensued when an independent panel of scientific and clinical experts was assembled at an FDA Advisory Committee meeting to deliberate over the approval of Aduhelm. The committee advised unanimously against the approval of aducanumab. Despite convincing evidence that Aduhelm effectively removes beta-amyloid plaques from the brain, experts argued that the two large phase 3 clinical trials— one positive and one negative—did not conclusively demonstrate a slowing in cognitive decline.

The approval of Aduhelm has not quelled any of the controversy surrounding the amyloid hypothesis. There remains a significant unmet need for disease-modifying AD therapeutics that result in a slowing—or indeed a reversal—of cognitive decline. The following post in this Alzheimer’s series will explore the next wave of AD drug development. We will place our focus beyond aberrant amyloid and tau protein pathology, and examine a multifactorial set of disease mechanisms, including inflammatory cascades, gut-brain signaling, and axonal transport.

Muzamil Saleem, PhD
Associate Scientific Director, ProEd Regulatory
Muz is a trained neuroscientist with a diverse skillset, combining a ten-year neurology-focused research career, scientific consulting experience and a three-year tenure in healthcare equity research on Wall Street before joining ProEd Regulatory—all supported by a passion for written and visual scientific communication. Connect with Muz on LinkedIn.


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  11. Shi L, Baird AL, Westwood S, et al. A Decade of Blood Biomarkers for Alzheimer’s Disease Research: An Evolving Field, Improving Study Designs, and the Challenge of Replication. J Alzheimers Dis. 2018;62(3):1181-1198.