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OCT as an Outcome Measure in Clinical Trials
Robert Bermel, MD Staff Neurologist and Medical Director
Mellen Center for Multiple Sclerosis
Disclosures
• Research support from Biogen and Genentech • Personal compensation for consulting: Biogen,
Genentech, Genzyme, Novartis
Why OCT as an outcome measure?
• A pathologically specific measure of: • Unmyelinated axons, in pRNFL • First-order sensory neurons, at the macula
• Directly related to: • Low contrast letter acuity • Visual QOL
• Optic neuritis as a model system • Reproducibility • Ease of patient participation • Changes over time • Sensitivity to treatment effect???
Typical scan protocol Cirrus
• Optic Disc cube 200x200
• Macular Cube 512x128
Quality Control Standards for scan completeness, signal strength, motion, scan obstruction/blink.
Spectralis • Glaucoma RNFL
- 768x496 with an ART of 100
• Axonal RNFL-N - 1536x496 with an ART
of 100
• Posterior Pole - 61 scan lines spaced
12µm apart, - 768 A-scans with an
ART of 25
Opt
ic N
erve
Hea
d M
acul
a
Trial design: Acute Optic Neuritis
placebo
Baseline Month 6 OCT OCT
active
Month 2 OCT
Month 4 OCT
Study drug (active or placebo)
Safety follow-up
Key Issues: • Timing of enrollment after optic neuritis • Controlling for swelling in the peripapillary RNFL
Sample size: n=35 per arm, measured at 6 months, if 50% treatment effect
Henderson et al Brain 2010; 133; 2592–2602
RNFL loss after AON
Henderson et al Brain 2010; 133; 2592–2602
Use fellow eye as control or GCIP thickness
Trial design overview: SPMS
placebo
Baseline Month 18 OCT OCT
active
Month 6 OCT
Month 12 OCT
Month 24 OCT
Key Issues: • Rate of change over time • Occurrence of ON during trial • Enrichment possible based on disease activity? Sample size: n=400-600 per arm to show 6.6uM difference between arms
Talman et al. Ann Neurol 2010
Efficacy Trials Incorporating OCT
Agent DesignAuthor/PI Phase OCTrole OCTresult Technology #Sites
erythropoe(nAON SühsKW 2 primary posi(ve TD 3
phenytoin AON Ra<opoulosR 2 primary posi(ve SD 2
opicinumab AON CadavidD 2 secondary NS SD 33
MSC MS ConnickP 2a secondary NS TD 1
MSC MS CohenJ 1-2 secondary NS SD 1
clemas(ne AON GreenA 2 secondary inprogress SD 1
ibudilast MS FoxR 2 secondary inprogress SD 28
others!
Phenytoin in acute optic neuritis
Raftopoulos R et al. Lancet Neurol. 2016; 15:259-69.
Opicinumab: RENEW trial
Cadavid D et al. Lancet Neurol 2017 Mar
Lessons: Timing of intervention Severity of ON
Logistics of OCT in Trials
• May be unfamiliar to traditional neurology sites • Potential operator variability • Multiple, evolving technologies
Roles of an OCT Reading Center
• Protocol development input • Instrument-specific manuals of operations • Site/technologist training, certification • Handling, storage, archiving of source images • Quantitative data management • On-study scan review and grading • Quality assurance with feedback to sites • Study closeout, query resolution, OCT database
lock
OCT Reading Center Data Flow
Site Digital OCT
Reading Center
Manual review/ grading
Quality feedback
Incidental findings
Master Study
Database
Resources
Neurology 2016;86:2303–2309
PLoSOne 2014
MS International May 2015
Takeaways:
• OCT is well-suited as an outcome measure in clinical trials targeting neuroprotection
• Trial designs include acute optic neuritis and SPMS
• Unique complexities apply to each trial design • OCT reading center can facilitate issues of
standardization, quality control, grading, and data management
• IMS VISUAL is paving the way for OCT to play a key role in demonstrating neuroprotection