EU/3/19/2232: Orphan designation for the treatment of amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a progressive disease of the nervous system, where nerve cells in the brain and spinal cord that control voluntary movement gradually deteriorate, causing loss of muscle function and paralysis. The exact causes are unknown but are believed to include genetic and environmental factors. The symptoms of ALS depend on which muscles weaken first, and include loss of balance, loss of control of hand and arm movement, and difficulty speaking, swallowing and breathing. ALS usually starts in mid-life and men are more likely to develop the disease than women.

ALS is a debilitating and life-threatening disease because of the gradual loss of function and its paralysing effect on muscles used for breathing, which usually leads to death from respiratory failure.

At the time of designation, amyotrophic lateral sclerosis affected approximately 1 in 10,000 people in the European Union (EU). This was equivalent to a total of around 52,000 people*, and is below the ceiling for orphan designation, which is 5 people in 10,000. This is based on the information provided by the sponsor and the knowledge of the Committee for Orphan Medicinal Products (COMP).

*Disclaimer: For the purpose of the designation, the number of patients affected by the condition is estimated and assessed on the basis of data from the European Union (EU 28), Norway, Iceland and Liechtenstein. This represents a population of 518,400,000 (Eurostat 2019).

At the time of designation, riluzole was authorised in the EU to treat ALS. Patients also received supportive treatment to relieve the symptoms of the disease, such as physiotherapy and breathing support.

The sponsor has provided sufficient information to show that the medicine might be of significant benefit for patients with ALS, because early studies showed that the progression of the disease was slower in patients treated with the medicine and suggested that the medicine might reduce symptoms that are not treated with the authorised medicine.

This assumption will need to be confirmed at the time of marketing authorisation, in order to maintain the orphan status.

This medicine contains bacteria known as Lactobacillus plantarum, which are commonly found in many fermented food products and in human saliva.

The way these bacteria work in the treatment of ALS is not fully understood, but they are thought to modify the composition of the bacteria normally present in the human gut in favour of bacteria that break down glutamate, a substance that at high levels is toxic to nerve cells. By reducing the level of glutamate, the medicine is expected to protect nerve cells from its harmful effects, thus delaying the progression of the disease.

The effects of the medicine have been evaluated in experimental models.

At the time of submission of the application for orphan designation, clinical trials with the medicine in patients with amyotrophic lateral sclerosis were ongoing.

At the time of submission, the medicine was not authorised anywhere in the EU for the treatment of amyotrophic lateral sclerosis. Orphan designation of Lactobacillus plantarum had been granted in the United States for treatment of ALS.

In accordance with Regulation (EC) No 141/2000, the COMP adopted a positive opinion on 15 November 2019, recommending the granting of this designation.

• the seriousness of the condition;
• the existence of alternative methods of diagnosis, prevention or treatment;
• either the rarity of the condition (affecting not more than 5 in 10,000 people in the EU) or insufficient returns on investment.

Designated orphan medicinal products are products that are still under investigation and are considered for orphan designation on the basis of potential activity. An orphan designation is not a marketing authorisation. As a consequence, demonstration of quality, safety and efficacy is necessary before a product can be granted a marketing authorisation.