A Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Safety, Pharmacodynamics and Pharmacokinetics of TW001 in Alzheimer Patients

Alzheimer*s Disease (AD) is one of the most common neurodegenerative disorders
affecting more than five million people in the United States alone. It accounts
for more than 80% of dementia cases worldwide and has an estimated prevalence
of 10-30% in people over 65 years of age. Clinical characteristics include
progressive cognitive decline and memory loss. Accumulation of amyloid β (Aβ)
plaques and neurofibrillary tangles of hyperphosphorylated tau protein are the
main pathological hallmarks of the disease. The exact cause of Alzheimer*s
Disease remains unknown, but it is common understanding that several factors
(e.g., genetic, environmental and lifestyle factors) play a role in disease
onset and progression. Different molecular and cellular mechanisms, including
oxidative stress, have been suggested to play a critical role in the
pathogenesis of AD. Treatment options for AD are limited and include
acetylcholinesterase inhibitors and a N-methyl D-aspartate receptor antagonist
(NMDA). These treatments, however, have a minimal impact on the progression of
the disease and target late stage aspects of the disease.

Edaravone is one of three metabolites produced as a result of exogenous
antipyrine biotransformation in mammals and is also referred to as norphenazone
or norantipyrine. It exerts anti-ischemic actions and is capable of reducing
oedema in the brain following ischemia/reperfusion injury.

Its potential in the treatment of cardiovascular disease (CVD), cerebrovascular
ischemia and cerebral oedema appears to be due to its action to reduce
oxidative and nitrosative stress as a free radical and peroxynitrite scavenger.

Edaravone targets multiple key AD pathways including Aβ, oxidative stress, and
GSK3β-Tau phosphorylation. It is anticipated that edaravone would be effective
in slowing AD disease progression by simultaneously blocking multiple cascades
leading to disease pathogenesis.

From the various published non-clinical studies described above, the mode of
action of edaravone in the treatment of Alzheimer*s Disease is thought to be
multifactorial, comprising:
- The mitigation of loss of neurons and dendrites caused by inflammatory and
oxidative stress processes;
- The attenuation of Aβ-induced oxidative stress and neurotoxicity;
- Reducing amyloid plague burden.
Most, if not all, of these activities are related to the oxidative and
nitrosative stress that is thought to play an essential role in the pathology
of Alzheimer*s Disease.

Primary objective:
The main objective of the present trial are:
• to evaluate the effect of TW001 on oxidative stress biomarkers
• to evaluate the safety of TW001 in patients with Alzheimer*s Disease

Secondary objective:
The secondary objective of the present trial is:
• to evaluate the pharmacokinetics of TW001 in patients with Alzheimer*s Disease

Exploratory objectives:
Exploratory objectives of the present trial are:
• to explore the early effect of TW001 on the CDR-SB and the Cognitive
Functional Composite (CFC) endpoint as a clinical outcome measure
• to explore the early effect of TW001 on a variety of individual biomarkers to
define a composite biomarker to be used in a follow-up, long-term clinical
study to predict disease progression

This is a double-blind, randomized, placebo-controlled, phase IIa proof of
concept study to evaluate the safety, pharmacodynamics and pharmacokinetics of
TW001 in patients with Alzheimer*s Disease.

Patients will be screened to assess whether they comply with all enrollment
criteria. Approximately 60 patients are planned to be enrolled, who will be
randomized 1:1 to TW001 and placebo. Treatments will be given in a fasted state.

Subjects will receive 100 mg TW001 or placebo once daily for 90 days.

The following assessments will be performed:
- Cognitive functioning by using Clinical Dementia Rating (CDR) and the
cognitive-functional composite (CFC).
- Pharmacodynamics and exploratory endpoints by collection of blood, CSF
sampling for the determination of oxidative stress biomarkers and biomarkers of
Alzheimer*s disease pathogenesis and progression
- Determination of oxidative stress biomarkers by urine sampling
- Pharmacokinetics by collecting blood sampling for determination of plasma
TW001
- Safety by measuring vital signs, 12-lead ECG, EEG, physical and neurological
examination, clinical safety laboratory tests and adverse events.

Double-blind treatment is planned to continue for 90 days. A patient that
discontinues for other reasons than for adverse events prior to the Day 30
assessment will be replaced. Replacement of patients will be considered in the
absence of significant safety events. The final decision for replacement will
be made by the Sponsor and will ensure a sufficient number of patients is
enrolled to meet the objectives of the trial. A patient that discontinues from
the trial after the Day 30 assessment will not be replaced.

TW001 or placebo is dispensed as granules for oral use and will be dissolved in
water prior to administration and taken on an empty stomach. The subject will
receive TW001 or placebo once daily.

Burden:
The patient and/or caregiver is asked to complete:
- Additional questionnaires;
- Diary on a weekly basis for 3 consecutive days.

Since the active substance in TW001 was already approved in Japan in 2001 for
the treatment of stroke and for ALS in Japan since 2015 and the USA since 2017,
more than 1.7 million patients have been treated with this drug. In general, it
was found to be safe and well tolerated. However, both the effect and the side
effects of the test drug TW001 have not yet been studied in patients suffering
from Alzheimer*s disease. The side effects of TW001 experiences in the previous
trials are:
- Bruising;
- Problems walking;
- Headache;
- Allergic reaction like skin rash, difficult breathing, wheezing, swelling
around the mouth, throat or eyes, sweating and fast pulse.

Risk during the trial are:
- Venapuncture: pain, bruising, swelling, fainting, infection and formation of
small blood clots;
- CSF puncture: Headache, vomiting, paresthesia, bleeding in spinal canal,
infection and damage of the spinal cord or nerves, resulting in weakening or
loss of feeling and paralysis.
- ECG: redness and itching caused by the stickly pads.

The following procedures will be performed:
- Physical examination, including vital signs;
- Neurological examination;
- ECG;
- EEG;
- Blood draw and urine collection;
- CSF;
- Completion of questionnaires and diary.