Alto Neuroscience (NYSE: ANRO) reported that ALTO-101 did not meet its primary EEG or cognitive endpoints versus placebo in a Phase II proof-of-concept study in cognitive impairment associated with schizophrenia (CIAS), prompting the company to discontinue independent development of the asset and redirect resources toward its lead program, ALTO-207, in treatment-resistant depression.
The Phase II trial (NCT06502964) was assessing ALTO-101 — a transdermal PDE4 inhibitor formulation — in adults with CIAS, enrolling 83 participants across the primary analysis set.
ALTO-101 produced a near-significant effect on theta inter-trial coherence (theta-ITC), an EEG measure correlated with cognitive performance, in the full analysis set (n=83; Cohen’s d=0.34, p=0.052). In a pre-specified subgroup of more cognitively impaired patients (n=59), the effect on theta-ITC reached nominal significance (d=0.44, p=0.03). The company also noted that theta-ITC improved from day 5 to day 10 of the trial, raising the possibility that a longer treatment duration could yield larger effects, though the primary endpoints were not met and these observations remain exploratory.
Tolerability was notable in one respect: nausea and vomiting rates were in line with placebo, a finding the company attributes to the pharmacokinetic profile of the transdermal formulation — a class-specific barrier that has historically constrained PDE4 inhibitor development. High rates of application site skin reactions were observed in both active and placebo arms, suggesting a formulation effect rather than a drug-specific signal.
ALTO-101 belongs to the PDE4 inhibitor class, which has long been associated with pro-cognitive effects in preclinical models but has faced tolerability limitations that have restricted clinical utility. The transdermal delivery approach was designed to circumvent the gastrointestinal side effects that have limited oral PDE4 inhibitors. The near-miss on theta-ITC — a measure that the company describes as correlated with cognitive performance across datasets — suggests some pharmacodynamic engagement, but the gap between that signal and statistical significance on primary endpoints is the critical interpretive question. Cross-trial comparisons are limited, but Biogen’s AMPA receptor potentiator BIIB104, a separate CIAS-targeted program that completed Phase II, but also failed to produce sufficient efficacy in this indication.
Alto has separately developed a modified-release oral formulation of ALTO-101 with an improved pharmacokinetic and tolerability profile relative to the immediate-release version. The company intends to explore partnering opportunities for this formulation, which is covered by a pending patent application, and believes it may have utility across multiple therapeutic areas beyond CIAS.
Within the same press release, Alto indicated that development of ALTO-207 remains on track to begin a Phase IIb study for treatment-resistant depression (TRD) later this year, and is now the company’s top priority. ALTO-207 is a fixed-dose combination of pramipexole, a dopamine D3/D2 agonist, and ondansetron, a 5-HT3 antagonist, designed to enable rapid titration to higher pramipexole doses by suppressing the dose-limiting nausea and vomiting that have historically prevented patients from reaching therapeutically relevant exposures. The planned Phase IIb trial is a randomized, double-blind, placebo-controlled study in approximately 178 adults with TRD who have experienced two to five prior treatment failures, evaluating ALTO-207 as adjunctive therapy.
The mechanistic rationale draws on the PAX-D study, published in The Lancet Psychiatry and conducted by the University of Oxford, which reported a Cohen’s d=0.87 effect size for pramipexole versus placebo at 12 weeks in depression — a figure the company characterizes as substantially larger than those seen with currently approved TRD treatments. Alto’s own Phase IIa trial of ALTO-207 met primary and secondary endpoints, and a 2025 FDA meeting is described as having positioned the company to advance toward Phase III and a potential NDA submission.
The TRD landscape ALTO-207 is entering contains one truly TRD-specific intranasal therapy — esketamine (Spravato), approved in 2019 and expanded to monotherapy in January 2025 — alongside oral atypical antipsychotic augmenters such as aripiprazole, brexpiprazole, and quetiapine that carry adjunctive MDD labels rather than TRD-specific indications. Olanzapine/fluoxetine (Symbyax) holds a TRD-specific oral label but is associated with metabolic burden. The dopamine D3-preferring agonism of pramipexole is mechanistically distinct from all currently approved options, and the fixed-dose combination strategy with ondansetron addresses the primary tolerability barrier that has previously prevented pramipexole from reaching therapeutic doses in this population. Cross-trial comparisons are limited by differences in patient populations, prior treatment histories, and endpoint definitions, and the PAX-D effect size for pramipexole alone does not directly predict what ALTO-207 will produce in a rigorously controlled registrational-track study.
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