Arbaclofen in fragile X syndrome: results of phase 3 trials

Abstract

Background: Arbaclofen improved multiple abnormal phenotypes in animal models of fragile X syndrome (FXS) and showed promising results in a phase 2 clinical study. The objective of the study is to determine safety and efficacy of arbaclofen for social avoidance in FXS.

Methods: Two phase 3 placebo-controlled trials were conducted, a flexible dose trial in subjects age 12-50 (209FX301, adolescent/adult study) and a fixed dose trial in subjects age 5-11 (209FX302, child study). The primary endpoint for both trials was the Social Avoidance subscale of the Aberrant Behavior Checklist-Community Edition, FXS-specific (ABC-C_FX). Secondary outcomes included other ABC-C_FX subscale scores, Clinical Global Impression-Improvement (CGI-I), Clinical Global Impression-Severity (CGI-S), and Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) Socialization domain score.

Results: A total 119 of 125 randomized subjects completed the adolescent/adult study (n = 57 arbaclofen, 62 placebo) and 159/172 completed the child study (arbaclofen 5 BID n = 38; 10 BID n = 39; 10 TID n = 38; placebo n = 44). There were no serious adverse events (AEs); the most common AEs included somatic (headache, vomiting, nausea), neurobehavioral (irritability/agitation, anxiety, hyperactivity), decreased appetite, and infectious conditions, many of which were also common on placebo. In the combined studies, there were 13 discontinuations (n = 12 arbaclofen, 1 placebo) due to AEs (all neurobehavioral). The adolescent/adult study did not show benefit for arbaclofen over placebo for any measure. In the child study, the highest dose group showed benefit over placebo on the ABC-C_FX Irritability subscale (p = 0.03) and Parenting Stress Index (PSI, p = 0.03) and trends toward benefit on the ABC-C_FX Social Avoidance and Hyperactivity subscales (both p < 0.1) and CGI-I (p = 0.119). Effect size in the highest dose group was similar to effect sizes for FDA-approved serotonin reuptake inhibitors (SSRIs).

Conclusions: Arbaclofen did not meet the primary outcome of improved social avoidance in FXS in either study. Data from secondary measures in the child study suggests younger patients may derive benefit, but additional studies with a larger cohort on higher doses would be required to confirm this finding. The reported studies illustrate the challenges but represent a significant step forward in translating targeted treatments from preclinical models to clinical trials in humans with FXS.

Keywords: Arbaclofen; FMR1; Fragile X syndrome; GABA agonist; Neurodevelopmental disorder; Targeted treatment.

Fig. 1

Design of adult/adolescent (a) and child (b) phase III arbaclofen studies

Fig. 2

Consort diagrams for adult/adolescent (a) and child (b) phase III arbaclofen studies

Fig. 3

Baseline and end-of-treatment scores (a) and change in scores (b) for the primary outcome measure, the ABC-FX-Social Avoidance subscore, in child study for placebo and highest dose (10 mg TID) arbaclofen groups

Fig. 4

Baseline and end-of-treatment scores (a, c) and change in scores (b, d) for the ABC-FX-Irritability subscale (a, b) and Parenting Stress Index (b, d), in child study for placebo and highest dose (10 mg TID) arbaclofen groups. Standard error bars represent standard error of the mean

Fig. 5

Dose responses for change in the CGI-I (a) and percent responders in responder analysis (b) in child study. Responders are defined as subjects with 25% improvement in the primary outcome ABC-C_FX Social Avoidance plus a CGI-I of 1 or 2