Neuroprotection (Acute Phase)

GM-1 Ganglioside

Gangliosides are naturally occurring molecules in nerve cell membranes. They are thought to have a role in neural development, as well as cellular recognition and neuronal communication (Yu et al. 2012). Synthetic versions of these molecules, such as monosialotetrahexosylganglioside GM1 sodium salt (commonly referred to as GM-1 ganglioside), have been used in the treatment of other neurological conditions such as stroke (Candelise & Ciccone 2002) and Parkinson’s disease (Schneider 1998). Although their exact mechanism of action is unknown, it is currently thought that gangliosides prevent cellular apoptosis, elicit anti-excitotoxic activity, and help initiate neurogenesis in the central nervous system (Mocchetti 2005).

Author Year
Country
Research Design
PEDro
Sample Size		 Methods Outcomes
Geisler et al. (2001)

Geisler et al. (2001)

Geisler et al. (2001)

USA

RCT

PEDro=8

N=760

 Population: Age range=17-69 yr; Gender: male=80%, female=20%; Level of injury: cervical-thoracic; Severity of injury: complete=63.4%, incomplete=36.6%.

Treatment: Patients were randomly assigned to receive either low dose monosialotetrahexosylganglioside (GM-1) ganglioside (Sygen®; 300 mg loading dose, followed by 100 mg/day for 56 days), high dose Sygen® (600 mg loading dose followed by 200 mg/day for 56 days), or placebo within 72 hr of injury. Treatments were administered through a gastric nasal tube. All patients initially received methylprednisolone sodium succinate (MPSS) according to National Acute Spinal Cord Injury Study (NASCIS) II guidelines for the first 24 hr before receiving Sygen® treatment.

Outcome Measures: The following at 6 months: neurological recovery using the AIS and the modified Benzel Classification scale, ASIA motor function, ASIA sensory function (pinprick and light touch), bowel and bladder function, sacral sensation, anal contraction, mortality, adverse event outcomes.

Chronicity: Mean time from injury to study treatment was 55.6 hr, 54 hr and 54.4 hr for Sygen® 100 mg, Sygen® 200 mg and placebo groups, respectively. 
  1. Overall, there were no significant differences in neurological recovery (both motor and sensory) between Sygen® groups or the placebo (p>0.05).
  2. Neurological recovery according to the Modified Benzel Classification scale occurred faster in patients receiving Sygen® (p<0.0128), but patients who received placebo reached the same level of improvement by 26 weeks. Also, patients who received Sygen® experienced a faster recovery of ASIA motor and sensory functions, but patients who received placebo reached the same degree of function.
  3. There were trends for patients receiving Sygen® to show improved bowel and bladder function, sacral sensation, and anal contraction compared to patients who received the placebo, but these were not significant (p<0.05).
  4. There were no significant differences in mortality between patients who received low dose Sygen®, high dose Sygen®, or placebo (p>0.05). Patients with complete injuries had a significantly higher mortality rate than patients with incomplete injuries (p=0.017).
  5. There were no significant differences in adverse event outcomes between patients who received Sygen® and patients who received placebo (p>0.05).
Geisler et al. 1990

Geisler et al. 1991

USA

RCT

PEDro=9

Ninitial=37, Nfinal=34

 Population: Age range=18-71 yr; Gender: not specified; Level of injury: cervical-thoracic; Severity of injury: complete=29%, incomplete=71%.

Treatment: Patients were randomly assigned to receive either monosialotetrahexosylganglioside (GM-1) ganglioside (GM-1 group; 100 mg/day) or placebo within 72 hr of injury. Amount of doses varied per patient. All patients received 250 mg methylprednisolone (MP) on admission followed by 125 mg MP every 6 hr for 72 hr.

Outcome Measures: The following after one year: neurological recovery based on Frankel grades, ASIA motor function, adverse event outcomes, death.

Chronicity: Mean time from injury to study entry was 48.2 hr and 51 hr for the GM-1 group and placebo group, respectively. 
  1. Patients who received GM-1 ganglioside improved in the form of at least 1 Frankel grade significantly more (p=0.034) than patients who received placebo. Significantly more patients who received GM-1 ganglioside were able to improve 2 or more grades compared to patients who received placebo (p=0.033).
  2. Patients who received GM-1 ganglioside experienced significantly more neurological recovery in the form of ASIA grade improvements compared to patients who received placebo (p=0.043).
  3. Significantly more patients who received GM-1 ganglioside were able to recover from ‘paralyzed’ to ‘useful power’ muscle grades on the ASIA motor scale compared to patients who received placebo (p=0.039). The authors noted that the improvement was due to the patients regaining useful function in paralyzed muscles rather than to paretic muscles improving in strength.
  4. No patients in the trial died and there were no significant differences in adverse event outcomes between the two groups (p>0.05).

Discussion

After two clinical trials using GM-1 ganglioside as a treatment option for acute SCI, it is still unclear whether this drug truly elicits significant benefits. The first small scale trial (Geisler et al. 1991, 1992) reported significant motor improvement compared to a placebo group; however, when the same authors later conducted a large scale multicenter trial, no effects were seen after the study period had ended, although the administration of GM-1 ganglioside appeared to expedite the recovery process (Geisler et al. 2001a, 2001b, 2001c). One potential reason could be the delay in treatment between the two studies; patients from the second trial did not begin to receive the drug until 24 hours after the injury to accommodate the initial mandatory dose of MP (Geisler et al. 2001c). It is possible that the results varied between these two studies because GM-1 ganglioside was administered following the optimal therapeutic window in the latter clinical trial.

Currently, there are no major adverse effects that result from using GM-1 ganglioside, although sporadic cases of Guillain-Barre syndrome have been reported (Chinnock & Roberts 2005). At this time, it is impossible to reach a conclusion regarding its effectiveness on improving feeling, movement, or quality of life for those who have acquired an SCI.

Conclusion

There is level 1b evidence (from one RCT: Geisler et al. 2001a, 2001b, 2001c) that GM-1 ganglioside is not effective in promoting neurological recovery in acute SCI individuals. However, there is level 1b evidence (from one RCT: Geisler et al. 1991, 1992) that GM-1 ganglioside may be effective in promoting neurological recovery in acute SCI individuals.

There is conflicting evidence regarding the effectiveness of GM-1 ganglioside for neurological recovery during the acute phase post-SCI.

Chapter Downloads
Patient Handouts
Toolkits and CPGs
Active Clinical Trials