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Randomized Controlled Trial
. 2020 May;26(5):760-768.
doi: 10.1038/s41591-020-0806-7. Epub 2020 Mar 30.

A randomized proof-of-mechanism trial applying the 'fast-fail' approach to evaluating κ-opioid antagonism as a treatment for anhedonia

Andrew D Krystal  1   2 , Diego A Pizzagalli  3 , Moria Smoski  4 , Sanjay J Mathew  5   6 , John Nurnberger Jr  7 , Sarah H Lisanby  8 , Dan Iosifescu  9 , James W Murrough  10 , Hongqiu Yang  11 , Richard D Weiner  4 , Joseph R Calabrese  12 , Gerard Sanacora  13 , Gretchen Hermes  13 , Richard S E Keefe  4 , Allen Song  4 , Wayne Goodman  5 , Steven T Szabo  4   14 , Alexis E Whitton  3   15 , Keming Gao  12 , William Z Potter  8
Affiliations
Randomized Controlled Trial

A randomized proof-of-mechanism trial applying the 'fast-fail' approach to evaluating κ-opioid antagonism as a treatment for anhedonia

Andrew D Krystal et al. Nat Med. 2020 May.

Abstract

The National Institute of Mental Health (NIMH) 'fast-fail' approach seeks to improve too-often-misleading early-phase drug development methods by incorporating biomarker-based proof-of-mechanism (POM) testing in phase 2a. This first comprehensive application of the fast-fail approach evaluated the potential of κ-opioid receptor (KOR) antagonism for treating anhedonia with a POM study determining whether robust target engagement favorably impacts the brain circuitry hypothesized to mediate clinical effects. Here we report the results from a multicenter, 8-week, double-blind, placebo-controlled, randomized trial in patients with anhedonia and a mood or anxiety disorder (selective KOR antagonist (JNJ-67953964, 10 mg; n = 45) and placebo (n = 44)). JNJ-67953964 significantly increased functional magnetic resonance imaging (fMRI) ventral striatum activation during reward anticipation (primary outcome) as compared to placebo (baseline-adjusted mean: JNJ-67953964, 0.72 (s.d. = 0.67); placebo, 0.33 (s.d. = 0.68); F(1,86) = 5.58, P < 0.01; effect size = 0.58 (95% confidence interval, 0.13-0.99)). JNJ-67953964, generally well tolerated, was not associated with any serious adverse events. This study supports proceeding with assessment of the clinical impact of target engagement and serves as a model for implementing the 'fast-fail' approach.

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Figures

Extended Data Figure 1.
Extended Data Figure 1.
Consort Diagram
Figure 1.
Figure 1.
(A) Summary of Study Flow. Within 30 days following screening patients returned for a baseline visit, which included administration of the Snaith-Hamilton Pleasure Scale (SHAPS)–, which assesses anhedonic symptoms, Hamilton Depression and Anxiety Rating Scales–, MRI, EEG, and the Probabilistic Reward Task (PRT)–. Patients were then randomized to JNJ-67953964 (10 mg) or placebo (1:1 ratio) for eight weeks. After 8 weeks of double-blind treatment, patients underwent MRI, EEG, PRT, SHAPS and anxiety and depression scales and treatment was discontinued. At the final visit (week 12), patients were assessed for possible adverse effects. The primary outcome measure was ventral striatal activation during reward anticipation assessed with fMRI during the Monetary Incentive Delay (MID) Task.– Secondary measures were the SHAPS and response bias in the PRT. The PRT is a computerized task that objectively measures participants’ ability to modulate behavior as a function of reinforcement history. (B) Trial Structure of the Monetary Incentive Delay (MID) Task. During fMRI, participants performed four runs of the MID (24 trials/run). For each trial (6 s), participants were presented with one of 3 possible cue shapes for 500 ms which signaled whether the upcoming trial had the potential for monetary gain (n=40; denoted by +$), potential for monetary losses (n=40; denoted by −$), or were no-incentive trials (n=40; denoted by 0$). Trial types were pseudo-randomly ordered within each run. After 2250–3750 ms, a red square target was presented for 150 ms. Participants were instructed that: for reward trials, they could win money if they responded quickly to the target; for penalty trials, they could avoid losing money if they responded quickly to the target; and for no-incentive trials there would be no monetary change, but they should still respond quickly to the target. Subjects received feedback 2400–3900 ms following target presentation. To standardize task difficulty, the 66th percentile of reaction times collected during a practice session was used to determine wins/penalties.
Figure 2:
Figure 2:
a. Location of ventral striatal ROI based on the Harvard-Oxford Subcortical Atlas. b. Mean signal intensity during reward anticipation within the ventral striatal ROI pre- and post-treatment with JNJ-67953964 and placebo. Error bars represent 95% confidence intervals surrounding the mean signal intensity.
Figure 3:
Figure 3:
a. Effects of study drug vs placebo on mean SHAPS score (intent-to-treat population). b. Effects of study drug vs placebo on mean PRT response bias (intent-to-treat population). Error bars represent 95% confidence intervals surrounding the means.
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