Negative trials matter, particularly in a disease as devastating as ALS, because we need failures to get to successes. DNL343 had a compelling rationale: it is a brain-penetrant small molecule that activates eIF2B and is designed to inhibit the integrated stress response, a cellular pathway involved in protein production and the response to cellular stress that can become persistently dysregulated in ALS; encouraging phase 1 data showed that the drug entered the brain and affected biomarkers of this pathway. But in this rigorous HEALEY ALS Platform Trial, 200 mg daily did not slow ALS progression, with no significant benefit on the primary combined measure of function and survival or on the major secondary outcomes. That is disappointing, but it is not wasted science: it tells us where this particular approach fell short, raises important questions about target engagement and the biological heterogeneity of ALS, and helps us design the next trial better. Thomas Edison is famously credited with reframing his repeated attempts to build the light bulb as, “I have not failed. I've just found 10,000 ways that won't work.” That is how we should view well-designed negative trials. Every carefully measured failure narrows the field, teaches us something, and hopefully moves us one experiment closer to a treatment that works.
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