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Saturday, September 8, 2018

How uncontrolled inflammation leads to brain cell loss


In a study of inflammation mechanisms in the brain, researchers from the University of Bonn in Germany have identified how, as we get older, a vicious cycle of poorly regulated inflammatory responses leads to the loss of brain cells.
Recently, those researchers conducted a study that investigated the mechanisms that regulate inflammation in the brain, what happens when they stop working properly, and why that may happen.
The cannabinoid receptor type 1 (CB1), they say, plays an important role in processing the “rush” sensation produced by cannabis.
It also appears to be involved in the regulation of inflammatory reactions in the brain.
If CB1 receptors fail to respond, this contributes to the development of chronic inflammation, which can eventually lead to the loss of brain cells. So reports the study paper, now published in the journal Frontiers in Molecular Neuroscience.

‘Brake signals’ for inflammation

The researchers say that the immune response in the brain is mounted via microglial cells, a type of specialized immune cell found in the central nervous system, which includes the brain and the spinal chord.
Microglia work by responding to bacteria and clearing out malfunctioning nerve cells. At the same time, they send signals to recruit other types of immune cells and trigger inflammation when needed.
However, if unregulated, an inflammatory reaction in the brain can misguidedly attack and damage healthy brain tissue.
“We know that so-called endocannabinoids play an important role in this,” explains study co-author Dr. Andras Bilkei-Gorzo. “[Endocannabinoids],” he goes on, “are messenger substances produced by the body that act as a kind of brake signal: [t]hey prevent the inflammatory activity of the glial cells.”
These messenger substances act by binding to certain receptors, one of which is CB1. A second one is cannabinoid receptor type 2 (CB2).
Microglial cells have low levels of CB2, and even less, or no, CB1, the researchers explain. Still, these immune cells will react to endocannabinoids despite this lack.
However, microglial cells have virtually no CB1 and very low level of CB2 receptors. They are therefore deaf on the CB1 ear. And yet they react to the corresponding brake signals — why this is the case, has been puzzling so far.”
Dr. Andras Bilkei-Gorzo

Neurons that ‘translate’ endocannabinoids

This is precisely the riddle that Dr. Bilkei-Gorzo and colleagues set out to solve in the current study. The investigation began with the observation that there is a certain group of neurons containing a large number of CB1 receptors.
The researchers worked with specially engineered mice, in which the CB1 receptors found in these neurons had been switched off.
Dr. Bilkei-Gorzo says, “The inflammatory activity of the microglial cells was permanently increased in these animals.” However, in mice with fully functioning CB1 receptors, inflammation was regulated as usual.
“Based on our results,” he says, “we assume that CB1 receptors on neurons control the activity of microglial cells.”
This has led the researchers to theorize that microglial cells do not communicate with other nerve cells directly. Instead, the scientists believe, microglial cells release endocannabinoids, and these bind to the CB1 receptors found in nearby neurons.
These neurons might be able to communicate with other nerve cells, and the immune response is thus indirectly regulated.
However, Dr. Bilkei-Gorzo and his team explain that with age, the production of endocannabinoids progressively decreases, leading to the improper regulation of immune responses and potentially to chronic inflammation.
“Since the neuronal CB1 receptors are no longer sufficiently activated, the glial cells are almost constantly in inflammatory mode,” says Dr. Bilkei-Gorzo.
“More regulatory neurons die as a result, so the immune response is less regulated and may become free-running,” he adds.

Can cannabis prevent brain aging?

The authors warn that, since the results were obtained in mice, they cannot yet be clearly extended to humans, and further research is needed to confirm that the same mechanisms apply.
Nevertheless, they are hopeful that, in the future, understanding these processes will mean that we will be able to develop drugs to act on them as necessary — particularly to prevent chronic inflammation.
Since the receptors activated to regulate inflammation are cannabinoid receptors, the team also suggests that cannabis may be a promising solution.
Tetrahydrocannabinol (THC), which is one of the main active substances in cannabis, is effective in activating CB1 — even when administered in low doses, the authors explain. This may help reduce inflammation and prevent the loss of brain cells.
Research conducted last year by the same scientists — alongside colleagues from other institutions across the world — also suggested that THC is able to restore cognitive function in the brains of aging mice, offering hope that the same may be possible for humans.

Diclofenac painkiller poses risk to heart health


One of the most widely used painkillers may pose a threat to cardiovascular health. This is the main takeaway of new research, recently published in The BMJ.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to alleviate pain.
In fact, according to the National Institutes of Health (NIH), about 30 million people in the United States take NSAIDs each year.
While NSAIDs are commonly recommended to treat inflammatory conditions, headaches, and fever, the drugs are thought to have some cardiovascular risks.
However, due to ethical concerns, these risks cannot be evaluated in clinical trials.
The European Society of Cardiology therefore carried out an extensive review of existing research that concluded that nonaspirin NSAIDs should not be prescribed to individuals at high risk of heart disease, nor should they be sold over the counter without issuing an “appropriate warning of their frequent cardiovascular complications.”
Now, a new study focuses on one NSAID in particular: diclofenac. Scientists led by Morten Schmidt, at Aarhus University Hospital in Denmark, set out to investigate the cardiovascular risks of taking this common painkiller, which some rank as “the most widely used […] NSAID in the world.

Cardiovascular risk 50 percent higher

Schmidt and team examined 252 national studies for information on over 6.3 million Danish people over a period of 20 years in 1996–2016. On average, the participants were aged 46–56.
During the study period, the researchers examined the cardiovascular risks of taking up diclofenac and compared them with the risks of starting paracetamol, ibuprofen, or naproxen.
After accounting for potentially confounding factors, the researchers found that within 30 days of taking up diclofenac, the rate of major cardiovascular problems — such as arrhythmia, ischemic strokeheart failure, and heart attack — was much higher compared with other NSAIDs.
Specifically, the risk of such adverse cardiovascular events was 50 percent higher among those who started taking diclofenac, compared with those who did not take it. Compared with taking paracetamol or ibuprofen, taking diclofenac raised cardiovascular risk by 20 percent.
Additionally, write the authors, “Diclofenac initiation […] increased the risk of upper gastrointestinal bleeding […] by approximately 4.5-fold compared with no initiation [and] 2.5-fold compared with initiation of ibuprofen or paracetamol.”
The cardiovascular threat also increased with the risk at baseline. In other words, the higher the risk of heart problems when the patients started taking the drug, the higher the risk of actually developing heart problems over the course of the treatment.
“Diclofenac poses a cardiovascular health risk compared with non-use, paracetamol use, and use of other traditional nonsteroidal anti-inflammatory drugs,” explain the authors.
Although the study is observational, they say — which means that no conclusions can be drawn about causality — the large sample size and the quality of the research is sufficiently “strong evidence to guide clinical decision-making.”
“Treatment of pain and inflammation with NSAIDs,” explain the authors, “may be worthwhile for some patients to improve quality of life despite potential side effects.”
Considering its cardiovascular and gastrointestinal risks, however, there is little justification to initiate diclofenac treatment before other traditional NSAIDs.”

Arrowhead may have way to go on catalysts


When a biotech stock shoots up 37.5% on a day when most biotech stocks are dropping it’s certainly worth taking a look at. So what happened with Arrowhead PharmaceuticalsInc. (NASDAQ:ARWR) stock? ARWR announced that it will present new clinical data at a World Gastroenterologists Summit, and the markets responded positively to encouraging clinical results from a Phase ½ trial for a drug treating hepatitis B virus infection.
On Thursday, Sept. 6, Arrowhead announced encouraging data for a single ascending dose of RNAi therapeutic ARO-HBV in healthy subjects with chronic hepatitis B, leading to a 37.5% jump in ARWR stock. The data show the results of patients in the lowest two dose cohorts (100mg and 200mg). The company said that all patients, eight in total, “achieved greater than 1.0 log10 reductions in circulating HBsAg.”
Arrowhead also demonstrated positive safety data. The only adverse events patients reported were mild and self-limiting injection site adverse events — occurring about 10% of the time. Upper respiratory tract infection and headache were the other most commonly reported events. At this weekend’s conference, scientists and doctors will get more details on the safety profile, dosage, and mechanism of action for the proprietary Targeted RNAi Molecules platform (the drug’s trademark name is TRIM). The high activity of ARO-HBV is encouraging at this early phase of the study.
Arrowhead released these key data points:
  • “Mean reduction of HBsAg was 2.0 log10 (99%) on day 85 in cohort 2b (100 mg) and 1.4 log10 (96%) on day 71 in cohort 3b (200 mg)…
  • Maximum reduction of HBsAg was 4.0 log10 (99.99%)
  • Minimum HBsAg reduction in all patients from cohorts 2b and 3b was 1.2 log10 (93%)
  • Activity was demonstrated in all patient types (HBeAg pos/neg, NUC naïve/treated)”
With dosing levels of 35, 100, 200, 300, and 400mg now complete, the company may continue to the next phase. The 1+ to 3 log reduction in surface antigen is a giant leap forward in developing a drug that treats HBV patients.

Valuation

Setting a price target on an early-stage biotech is mostly a guess. The company has no cash flow, so it is not possible to assign an accurate fair value on ARWR stock. Still, Arrowhead’s future performance is encouraging. Per Simply Wall St., Arrowhead is expected to grow its annual earnings by 39.5%. This is a rate that is well above the U.S. market average of 16% and the biotech annual growth rate average of 23.6%. If it brings the product to market, revenue could potentially grow 53% annually, compared to the biotech average of 18.5%.
On the stock market, Arrowhead stock’s rally is even more impressive because the iShares Nasdaq Biotechnology ETF (NASDAQ:IBB) fell 1.78% on Sep 6. And Gilead Sciences (NASDAQ:GILD) fell 2.21% on Thursday. Gilead, which trades at a P/E of just 12.5 times, makes Tenofovir Alafenamide, a drug that treats chronic hepatitis B virus.
Of the six analysts publishing a 12-month price target for ARWR stock in the last three months, the average price target is $21.42, implying upside of 10.5% (source: Tipranks).

System that owes Community Health over $28 million files for bankruptcy


A Knoxville-based health system that has purchased hospitals from Community Health Systems Inc. is seeking bankruptcy protection.
Curae Health Inc. and its three Mississippi hospitals all filed for Chapter 11 bankruptcy on Aug. 24, according to filings with the United States Bankruptcy Court for the Middle District of Tennessee.
Franklin-based CHS (NYSE: CYH), Nashville’s second-largest publicly traded health care company, sold the three facilities and a Florida hospital to Curae in September 2016 for $51 million, according to the filings. Curae currently owes CHS more than $28.6 million, according to its bankruptcy filing.
The facilities were among the first CHS sold as part of its plan to pay down debt following the $7.6 billion purchase of Florida-based Health Management Associates in 2014. The company has now sold more than 30 hospitals.
Becker’s Hospital Review reported that in court documents, Curae President and CEO Stephen Clapp said the purchase of the three hospitals made financial sense at the time but that their revenue dropped dramatically after the transaction closed. The company also struggled to pay for new electronic health record systems.
“This was a result of using CHS information systems longer than anticipated and the inability to secure permanent information system financing,” Clapp said in the filings.
The company and the three hospitals, which Curae plans to sell, have $96 million in liabilities and $3.4 million in cash, according to filings.
The Mississippi hospitals are: Gilmore Memorial Hospital in Amory, Panola Medical Center in Batesville and Northwest Mississippi Medical Center in Clarksdale.

Blood tester Guardant Health files for Nasdaq IPO


Cancer blood test maker Guardant Health plans to go public, filing an initial public offering on the Nasdaq using the symbol GH.
Its preliminary filing proposes a $100 million offering, but the Redwood City, California-based company describes that number as an estimate solely for calculating registration fees and is subject to change. The total number of shares and price per share have not yet been disclosed.
A member of last year’s class of the FierceMedTech Fierce 15, Guardant raised $360 million in May 2017 to sequence tumor DNA from 1 million cancer patients. The company describes its Guardant360 assay as the most widely ordered comprehensive liquid biopsy on the market, with over 5,000 oncologists ordering more than 70,000 tests since its 2014 launch, to scan patient blood draws for 73 cancer genes.
In 2017 alone, Guardant sold 25,754 tests to clinical customers, up from 18,643 the year before, as well as 6,141 to biopharma customers, up from 1,830.
In its prospectus, Guardant approximated the U.S. market for its current and investigational blood testing products at more than $35 billion—including applications for clinicians and industry customers across all stages of cancer, such as early screening, recurrence detection and late-stage therapy selection.
Last year the company brought in $49.8 million in total revenue, compared to $36.1 million in just the first half of 2018—with net losses of $83.2 million and $35.5 million, respectively.

While its Guardant360 test is not required to be approved by the FDA under current regulations, the company is planning to submit a premarket approval application in a bid to improve its tests’ coverage and reimbursements. The FDA granted the test a breakthrough device designation in January.
“We believe that FDA approval will become increasingly important for diagnostic tests to gain commercial adoption both in the United States and abroad,” the company wrote in its prospectus. “We also intend to pursue regulatory approvals in specific markets outside of the United States, including in Japan and China.”
In addition, Guardant has established a joint venture with the Tokyo-based conglomerate SoftBank, which led last year’s $360 million funding round, to assist with the commercialization of its products in Asia, the Middle East and Africa, with an initial focus on Japan.

Shionogi One-Dose Flu Drug Shows Promise


 An experimental single-dose flu drug shows promise as a new way to alleviate the misery of influenza, researchers say.
The drug — called baloxavir — worked better than no treatment in one phase of a new study. The study also found it as effective as the current standard drug, oseltamivir (Tamiflu), at controlling symptoms such as coughing, sore throat, headache, fever, muscle and joint pain, and fatigue.
Moreover, in light of concerns about flu-drug resistance, most patients treated with baloxavir responded as expected, the study authors said.
“There are few approved influenza antivirals, and current treatments have limitations,” said study lead author Dr. Frederick Hayden, of the University of Virginia School of Medicine.
“For example, currently circulating influenza viruses are resistant to the older class of antivirals,” he said. These include the drugs amantadine (brand name Symmetrel) and rimantadine (Flumadine).
Resistance is also growing to the class of drugs including widely used Tamiflu and Relenza (zanamivir), Hayden said. “Consequently, there are medical needs for new anti-influenza agents with different mechanisms of action and greater potency,” he added.
Hayden, professor emeritus of clinical virology and medicine, said the new study indicates that baloxavir resolves flu symptoms as quickly, effectively and safely as current options, without yet raising concerns about resistance. It also demonstrated “significantly greater antiviral effects,” he added.
Also, while Tamiflu must be taken twice a day for five days, baloxavir requires just one dose.
The investigation was funded by the drug company Shionogi, Inc., which developed and manufactures baloxavir.
Baloxavir is approved for use in Japan. In the United States, it remains an “investigational drug,” with the U.S. Food and Drug Administration expected to decide on approval by the end of this year.
The new study, which was published Sept. 6 in the New England Journal of Medicine, unfolded in two trials, both involving otherwise healthy flu patients at low risk for influenza complications.
One trial was conducted during the 2015-2016 flu season. About 400 patients, aged 20 to 64, received one of three doses of baloxavir (ranging from 10 to 40 milligrams) or a placebo. Flu symptoms eased notably faster among all three baloxavir groups, compared with placebo (untreated) patients, the findings showed.
The following flu season, nearly 1,100 patients, aged 12 to 64, were treated with baloxavir or Tamiflu. The drugs relieved symptoms in roughly the same time period, with similar side-effect risk.
However, about 10 percent of the baloxavir patients had a less than robust response to the drug. Hayden acknowledged that “the clinical and public health implications of reduced susceptibility to baloxavir are not fully understood.”
Dr. Timothy Uyeki, author of an accompanying journal editorial, is Chief Medical Officer of the Influenza Division at the U.S. Centers for Disease Control and Prevention.
“There is a need for antiviral drugs with new mechanisms of action,” he agreed.
Uyeki highlighted the benefit of baloxavir’s single-dose regimen. Besides its convenience, it “avoids concerns about compliance with a five-day treatment course of oseltamivir,” he said.
But he also stressed the need for further testing.
It remains unclear what benefits might accrue from combining baloxavir with Tamiflu, Uyeki noted.
Also, he cautioned, the current research only included otherwise healthy people aged 12 to 64 who were not at high risk for flu complications. Whether baloxavir will benefit high-risk groups — young children, the elderly, pregnant women and others with underlying chronic medical conditions — remains unknown, Uyeki said.
“A lot more studies are needed of the clinical benefit of baloxavir treatment of influenza in high-risk outpatients,” he added.
More information
There’s more on flu treatment at the U.S. National Institute of Allergy and Infectious Diseases.
SOURCES: Frederick G. Hayden, M.D., professor emeritus, clinical virology, and medicine, University of Virginia School of Medicine, Charlottesville, Va.; Tim Uyeki, M.D., MPH, MPP, chief medical officer, influenza division, National Center for Immunization and Respiratory Diseases, U.S. Centers for Disease Control and Prevention, Atlanta; Sept. 6, 2018, New England Journal of Medicine

Trupanion’s Murky Regulatory Quagmire (At Least ~31% Of Rev At Risk)


Trupanion offers Pet insurance through referrals from Veterinarians via the “Trupanion Express” software.
The company has previously leaned on the fact that they do not instruct their sales people (Territory Partners) or Veterinarians to specifically “solicit” insurance.
However, both of those parties are directly compensated when a patient becomes a plan holder.
The laws around referrals differ from state to state, but we believe that 15 states specifically prohibit referral payments and that those states represent about 30% of TRUP Revenue.

While you were in the Hampton’s during the last few weeks of August, I published two pieces on TRUP “Trupanion: A Regulatory Icarus With 75% Potential Downside” that was met with great anger from the company and subsequently followed by “Trupanion: A Moonshot Valuation With Lingering Questions“. The company has still not answered the three simple questions that I posed to them:
  1. Do you – or have you this calendar year – rewarded veterinarian clinics for points “based off of certificates issued at your [the veterinarian] hospital”?
  2. Do you – or have you this calendar year – provided cash rewards to your territory partners based off of the successful conversion of a new policyholder?
  3. Do you provide training to the veterinarians and their staff that they are specifically NOT allowed to offer or comment on specific insurance products without being a licensed agent?
These questions are worded specifically as they speak directly to the roll the compensation structure plays in establishing the potential violation of the referral laws cited in the previous pieces. Although I think there are lots of potential violations of the state insurance regulatory structure when a firm is paying both the Veterinarian and their third party marketing sales force off of the sale of insurance, I spent the last week refining my thoughts on the referral laws vs. solicitation laws and came to a few conclusions. Most importantly that around 31% of the company’s revenue is derived in states that specifically prohibit payment for referrals based on the successful sale of insurance. Specifically, that’s 13 states that don’t allow for referral payments based on the successful sale of insurance and 2 states that don’t allow for the payment of any referral.