I hear you on the only, as that puts a positive spin on it. For example, how many of the >=10% improvers were super responders? Here's the problem though. They don't reveal this, but they also don't reveal how many of the controls (bad ears) were super responders either. All we know from the attached graph is that there were also some bad ears that improved by >=10% (that also tells us that it may be possible to improve by 10% by chance). I would think if the treated ears saw super responders, but the untreated ears did not, they would show this off somehow.
The other issue with regards to the logic that the super responders were all moderate SNHL (true), is that the Phase 1/2 study lacked any placebo
participants that were moderate SNHL in WR. Hence, it would be far more interesting to see a comparison between the groups in terms of number of super responders.
There's also the fact that they recruited for Phase 2a with the intention of getting more people like the super responders from Phase 1/2. It was still a flop.
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The only true "misinformation" I see but it's a big one and repeated often is that the audiogram measures hearing broadly (vs just outer hair cells) and that without audiogram changes, the drug can't possibly do anything and therefore it is a guaranteed flop. But:
a) IHCs are both important for hearing (and tinnitus in some cases) and seem to be the structure more important for loudness hyperacusis. No one has to take my word for it, look these things up.
b) If we also know (based on many studies), that IHC loss doesn't effect hearing until you have lost quite a lot of them, then the super responders vs more mild/moderate responders just makes sense. The heterogeneity is not in delivery in these cases, it would be due to the individual cochlear make up of the responders.
Because of this: we don't know what it could actually do for OHCs as the drug was given, if say there is an IHC preference. Multi dosing at longer intervals could produce extremely different results here.
Anyway, Diesel also posted a very interesting rat study that showed if you only selectively destroyed one of the 3 OHC rows (there is a toxin that does this if dosed a certain way per the study) then the audiogram only changes by 5-1 0dB. If that holds true for people, you would have to multi dose to get appreciable audiogram changes but it now appears that rapid multi dosing is problematic.
But, yes, the point has been made that the drug has a penetrance problem for sure. It likely only gets to 6 kHz-8 kHz tops in this formulation and rapid multi dosing can't alleviate this because it's harmful for the effectiveness. BUT, that doesn't mean the drug "doesn't work."
It clearly does something very significant single dose for the right patient (one with a lot of IHC damage it looks like) if you believe the Phase 1 data wasn't fraud of some sort.
It also doesn't mean it does nothing for OHCs. If the rat study is similar in people, it means some people in the single dose group (presumably that had fairly normal IHCs) would get 5-10 dB changes and those would represent actual changes and not audiogram variability. It's not too far fetched to think that something akin to lateral inhibition could keep all 3 rows of OHCs from regrowing all at once (or any number of other possibilities). That's why the individual data is important too. If individuals are getting 5-10 dB changes across a few frequencies without word score changes this could be very significant.
I could see how this seems like juggling too many variables to fit but that's how multi factorial medicine is. It's complicated and sometimes it's hard to put it all together. To give you a vet example, you can't regulate a diabetic dog's insulin if they have a significant untreated UTI because it causes insulin resistance. This took a long time for the profession to figure out as a co-factor because it's not very obvious or intuitive. And the only way you figure out these individual factors is to look at the data. What makes *this* case different?
Until you answer that "why", you can't make broad claims about the effectiveness of the drug (except that you could use pharmacokinetic data to say that it doesn't diffuse past 6 kHz in its current form and rapid multi dosing to correct this is problematic, so reformulation or another technology would be required for deeper penetrance). I think that issue is a fair one to conclude with the evidence so far.