1
|
Mahlknecht P, Poewe W. Pharmacotherapy for Disease Modification in Early Parkinson's Disease: How Early Should We Be? JOURNAL OF PARKINSON'S DISEASE 2024:JPD230354. [PMID: 38427503 DOI: 10.3233/jpd-230354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Slowing or halting progression continues to be a major unmet medical need in Parkinson's disease (PD). Numerous trials over the past decades have tested a broad range of interventions without ultimate success. There are many potential reasons for this failure and much debate has focused on the need to test 'disease-modifying' candidate drugs in the earliest stages of disease. While generally accepted as a rational approach, it is also associated with significant challenges around the selection of trial populations as well as trial outcomes and durations. From a health care perspective, intervening even earlier and before at-risk subjects have gone on to develop overt clinical disease is at the heart of preventive medicine. Recent attempts to develop a framework for a biological definition of PD are aiming to enable 'preclinical' and subtype-specific diagnostic approaches. The present review addresses past efforts towards disease-modification, including drug targets and reasons for failure, as well as novel targets that are currently being explored in disease-modification trials in early established PD. The new biological definitions of PD may offer new opportunities to intervene even earlier. We critically discuss the potential and challenges around planning 'disease-prevention' trials in subjects with biologically defined 'preclinical' or prodromal PD.
Collapse
Affiliation(s)
- Philipp Mahlknecht
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| |
Collapse
|
2
|
Mahlknecht P, Marini K, Werkmann M, Poewe W, Seppi K. Prodromal Parkinson's disease: hype or hope for disease-modification trials? Transl Neurodegener 2022; 11:11. [PMID: 35184752 PMCID: PMC8859908 DOI: 10.1186/s40035-022-00286-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/01/2022] [Indexed: 12/24/2022] Open
Abstract
The ultimate goal in Parkinson's disease (PD) research remains the identification of treatments that are capable of slowing or even halting the progression of the disease. The failure of numerous past disease-modification trials in PD has been attributed to a variety of factors related not only to choosing wrong interventions, but also to using inadequate trial designs and target populations. In patients with clinically established PD, neuronal pathology may already have advanced too far to be modified by any intervention. Based on such reasoning, individuals in yet prediagnostic or prodromal disease stages, may provide a window of opportunity to test disease-modifying strategies. There is now sufficient evidence from prospective studies to define diagnostic criteria for prodromal PD and several approaches have been studied in observational cohorts. These include the use of PD-risk algorithms derived from multiple established risk factors for disease as well as follow-up of cohorts with single defined prodromal markers like hyposmia, rapid eye movement sleep behavior disorders, or PD gene carriers. In this review, we discuss recruitment strategies for disease-modification trials in various prodromal PD cohorts, as well as potential trial designs, required trial durations, and estimated sample sizes. We offer a concluding outlook on how the goal of implementing disease-modification trials in prodromal cohorts might be achieved in the future.
Collapse
|
3
|
Vijiaratnam N, Simuni T, Bandmann O, Morris HR, Foltynie T. Progress towards therapies for disease modification in Parkinson's disease. Lancet Neurol 2021; 20:559-572. [PMID: 34146514 DOI: 10.1016/s1474-4422(21)00061-2] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 02/04/2021] [Accepted: 02/12/2021] [Indexed: 12/12/2022]
Abstract
The development of interventions to slow or halt the progression of Parkinson's disease remains a priority for patients and researchers alike. To date, no agents have been shown to have unequivocal evidence of disease-modifying effects in Parkinson's disease. The absence of disease-modifying treatments might relate not only to inadequate approaches for the selection of therapeutic candidates but also to insufficient attention to detail in clinical trial design. Better understanding of Parkinson's disease pathogenesis associated with advances in laboratory models, the use of objective biomarkers of disease progression and target engagement, and a focus on agents known to be safe for human use, alongside the use of precision medicine approaches, should together greatly increase the likelihood for successful identification of disease-modifying treatments for Parkinson's disease.
Collapse
Affiliation(s)
- Nirosen Vijiaratnam
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK; The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Tanya Simuni
- Parkinson's Disease and Movement Disorders Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Oliver Bandmann
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Huw R Morris
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK; The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK; The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
| |
Collapse
|
4
|
Vijiaratnam N, Girges C, Auld G, Chau M, Maclagan K, King A, Skene S, Chowdhury K, Hibbert S, Morris H, Limousin P, Athauda D, Carroll CB, Hu MT, Silverdale M, Duncan GW, Chaudhuri R, Lo C, Del Din S, Yarnall AJ, Rochester L, Gibson R, Dickson J, Hunter R, Libri V, Foltynie T. Exenatide once weekly over 2 years as a potential disease-modifying treatment for Parkinson's disease: protocol for a multicentre, randomised, double blind, parallel group, placebo controlled, phase 3 trial: The 'Exenatide-PD3' study. BMJ Open 2021; 11:e047993. [PMID: 34049922 PMCID: PMC8166598 DOI: 10.1136/bmjopen-2020-047993] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Parkinson's disease (PD) is a common neurodegenerative disorder with substantial morbidity. No disease-modifying treatments currently exist. The glucagon like peptide-1 receptor agonist exenatide has been associated in single-centre studies with reduced motor deterioration over 1 year. The aim of this multicentre UK trial is to confirm whether these previous positive results are maintained in a larger number of participants over 2 years and if effects accumulate with prolonged drug exposure. METHODS AND ANALYSIS This is a phase 3, multicentre, double-blind, randomised, placebo-controlled trial of exenatide at a dose of 2 mg weekly in 200 participants with mild to moderate PD. Treatment duration is 96 weeks. Randomisation is 1:1, drug to placebo. Assessments are performed at baseline, week 12, 24, 36, 48, 60, 72, 84 and 96 weeks.The primary outcome is the comparison of Movement Disorders Society Unified Parkinson's Disease Rating Scale part 3 motor subscore in the practically defined OFF medication state at 96 weeks between participants according to treatment allocation. Secondary outcomes will compare the change between groups among other motor, non-motor and cognitive scores. The primary outcome will be reported using descriptive statistics and comparisons between treatment groups using a mixed model, adjusting for baseline scores. Secondary outcomes will be summarised between treatment groups using summary statistics and appropriate statistical tests to assess for significant differences. ETHICS AND DISSEMINATION This trial has been approved by the South Central-Berkshire Research Ethics Committee and the Health Research Authority. Results will be disseminated in peer-reviewed journals, presented at scientific meetings and to patients in lay-summary format. TRIAL REGISTRATION NUMBERS NCT04232969, ISRCTN14552789.
Collapse
Affiliation(s)
- Nirosen Vijiaratnam
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Christine Girges
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Grace Auld
- The Comprehensive Clinical Trials Unit, UCL, London, UK
| | - Marisa Chau
- The Comprehensive Clinical Trials Unit, UCL, London, UK
| | - Kate Maclagan
- The Comprehensive Clinical Trials Unit, UCL, London, UK
| | - Alexa King
- The Comprehensive Clinical Trials Unit, UCL, London, UK
| | - Simon Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, UK
| | | | - Steve Hibbert
- The Comprehensive Clinical Trials Unit, UCL, London, UK
| | - Huw Morris
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Patricia Limousin
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Dilan Athauda
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Camille B Carroll
- Applied Parkinson's Research Group, University of Plymouth, Plymouth, UK
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Michele T Hu
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
- Oxford Parkinson's Disease Centre, University of Oxford, Oxford, UK
- Department of Clinical Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Monty Silverdale
- Department of Neurology and Neurosurgery, University of Manchester, Greater Manchester, UK
| | - Gordon W Duncan
- Western General Hospital, NHS Lothian, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | - Ray Chaudhuri
- Parkinson's Foundation International Centre of Excellence, King\'s College London, London, UK
| | - Christine Lo
- Oxford Parkinson's Disease Centre, University of Oxford, Oxford, UK
| | - Silvia Del Din
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alison J Yarnall
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle, UK
| | - Lynn Rochester
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - John Dickson
- Department of Nuclear Medicine, University College London Hopsitals NHS Trust, London, UK
| | - Rachael Hunter
- Research Dept of Primary Care and Population Health, University College London, London, UK
| | - Vincenzo Libri
- Leonard Wolfson Experimental Neurology Centre, National Hospital for Neurology & Neurosurgery, London, UK
- University College London, London, UK
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| |
Collapse
|
5
|
Devos D, Hirsch E, Wyse R. Seven Solutions for Neuroprotection in Parkinson's Disease. Mov Disord 2020; 36:306-316. [PMID: 33184908 DOI: 10.1002/mds.28379] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/07/2020] [Accepted: 10/21/2020] [Indexed: 12/21/2022] Open
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder characterized by loss of dopaminergic neurons in the substantia nigra and accumulation of iron and alpha-synuclein; it follows a characteristic pattern throughout the nervous system. Despite decades of successful preclinical neuroprotective studies, no drug has then shown efficacy in clinical trials. Considering this dilemma, we have reviewed and organized solutions of varying importance that can be exclusive or additive, and we outline approaches to help generate successful development of neuroprotective drugs for PD: (1) select patients in which the targeted mechanism is involved in the pathological process associated with the monitoring of target engagement, (2) combine treatments that target multiple pathways, (3) establish earliest interventions and develop better prodromal biomarkers, (4) adopt rigorous methodology and specific disease-relevant designs for disease-modifying clinical trials, (5) customize drug with better brain biodistribution, (6) prioritize repurposed drugs as a first line approach, and (7) adapt preclinical models to the targeted mechanisms with translational biomarkers to increase their predictive value. © 2020 International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- David Devos
- Department of Medical Pharmacology, Expert Center for Parkinson, CHU-Lille, Lille Neuroscience & Cognition, Inserm, zUMR-S1172, LICEND, University of Lille, Lille, France
| | - Etienne Hirsch
- Institut du Cerveau-ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
| | - Richard Wyse
- The Cure Parkinson's Trust, London, United Kingdom
| |
Collapse
|
6
|
Hung AY, Schwarzschild MA. Approaches to Disease Modification for Parkinson's Disease: Clinical Trials and Lessons Learned. Neurotherapeutics 2020; 17:1393-1405. [PMID: 33205384 PMCID: PMC7851299 DOI: 10.1007/s13311-020-00964-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/16/2022] Open
Abstract
Despite many clinical trials over the last three decades, the goal of demonstrating that a treatment slows the progression of Parkinson's disease (PD) remains elusive. Research advances have shed new insight into cellular pathways contributing to PD pathogenesis and offer increasingly compelling therapeutic targets. Here we review recent and ongoing clinical trials employing novel strategies toward disease modification, including those targeting alpha-synuclein and those repurposing drugs approved for other indications. Active and passive immunotherapy approaches are being studied with the goal to modify the spread of alpha-synuclein pathology in the brain. Classes of currently available drugs that have been proposed to have potential disease-modifying effects for PD include calcium channel blockers, antioxidants, anti-inflammatory agents, iron-chelating agents, glucagon-like peptide 1 agonists, and cAbl tyrosine kinase inhibitors. The mechanistic diversity of these treatments offers hope, but to date, results from these trials have been disappointing. Nevertheless, they provide useful lessons in guiding future therapeutic development.
Collapse
Affiliation(s)
- Albert Y Hung
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Michael A Schwarzschild
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- MassGeneral Institute for Neurodegenerative Disease, 114 16th Street, Charlestown, MA, 02129, USA
| |
Collapse
|
7
|
Parambi DGT. Treatment of Parkinson's Disease by MAO-B Inhibitors, New Therapies and Future Challenges - A Mini-Review. Comb Chem High Throughput Screen 2020; 23:847-861. [PMID: 32238135 DOI: 10.2174/1386207323666200402090557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/30/2019] [Accepted: 01/23/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND One of the most prevalent neurodegenerative diseases with increasing age is Parkinson's disease (PD). Its pathogenesis is unclear and mainly confined to glutamate toxicity and oxidative stress. The dyskinesia and motor fluctuations and neuroprotective potential are the major concerns which are still unmet in PD therapy. OBJECTIVE This article is a capsulization of the role of MAO-B in the treatment of PD, pharmacological properties, safety and efficiency, clinical evidence through random trials, future therapies and challenges. CONCLUSION MAO-B inhibitors are well tolerated for the treatment of PD because of their pharmacokinetic properties and neuroprotective action. Rasagiline and selegiline were recommended molecules for early PD and proven safe and provide a modest to significant rise in motor function, delay the use of levodopa and used in early PD. Moreover, safinamide is antiglutamatergic in action. When added to Levodopa, these molecules significantly reduce the offtime with a considerable improvement of non-motor symptoms. This review also discusses the new approaches in therapy like the use of biomarkers, neurorestorative growth factors, gene therapy, neuroimaging, neural transplantation, and nanotechnology. Clinical evidence illustrated that MAOB inhibitors are recommended as monotherapy and added on therapy to levodopa. A large study and further evidence are required in the field of future therapies to unwind the complexity of the disease.
Collapse
Affiliation(s)
- Della G T Parambi
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Jouf University, Sakaka, Jouf, Saudi Arabia
| |
Collapse
|
8
|
Foltynie T, Langston JW. Therapies to Slow, Stop, or Reverse Parkinson's Disease. JOURNAL OF PARKINSONS DISEASE 2019; 8:S115-S121. [PMID: 30584162 PMCID: PMC6311371 DOI: 10.3233/jpd-181481] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Our understanding of PD pathophysiology is vastly improved compared to the situation 20 years ago. We have identified the major genetic risks for PD, we now have far more representative animal models of the disease, and we can be inspired by the early successes of others using Antisense Oligonucleotide and vaccination approaches in other neurodegenerative diseases. We also have a broad range of repurposed drugs showing the first signals of potential efficacy in the translational pipeline which are being driven forward through the various clinical trial stages. We believe we can be optimistic that the next 20 years will be a time for major breakthroughs towards the discovery of therapies that may slow, stop, or reverse PD.
Collapse
Affiliation(s)
- Tom Foltynie
- Department of Clinical and Movement Neurosciences, UCL Institute of Neurology & The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - J William Langston
- Department of Pathology, Associate Director, Stanford Udall Center, Stanford, CA, USA
| |
Collapse
|
9
|
Peball M, Werkmann M, Ellmerer P, Stolz R, Valent D, Knaus HG, Ulmer H, Djamshidian A, Poewe W, Seppi K. Nabilone for non-motor symptoms of Parkinson's disease: a randomized placebo-controlled, double-blind, parallel-group, enriched enrolment randomized withdrawal study (The NMS-Nab Study). J Neural Transm (Vienna) 2019; 126:1061-1072. [PMID: 31129719 PMCID: PMC6647387 DOI: 10.1007/s00702-019-02021-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 05/22/2019] [Indexed: 01/07/2023]
Abstract
Although open-label observations report a positive effect of cannabinoids on non-motor symptoms (NMS) in Parkinson's disease (PD) patients, these effects remain to be investigated in a controlled trial for a broader use in NMS in PD patients. Therefore, we decided to design a proof-of-concept study to assess the synthetic cannabinoid nabilone for the treatment of NMS. We hypothesize that nabilone will improve NMS in patients with PD and have a favorable safety profile. The NMS-Nab Study is as a mono-centric phase II, randomized, placebo-controlled, double-blind, parallel-group, enriched enrollment withdrawal study. The primary efficacy criterion will be the change in Movement Disorders Society-Unified Parkinson's Disease-Rating Scale Part I score between baseline (i.e. randomization) and week 4. A total of 38 patients will have 80% power to detect a probability of 0.231 that an observation in the treatment group is less than an observation in the placebo group using a Wilcoxon rank-sum test with a 0.050 two-sided significance level assuming a true difference of 2.5 points between nabilone and placebo in the primary outcome measure and a standard deviation of the change of 2.4 points. The reduction of harm through an ineffective treatment, the possibility of individualized dosing, the reduction of sample size, and the possible evaluation of the influence of the placebo effect on efficacy outcomes justify this design for a single-centered placebo-controlled investigator-initiated trial of nabilone. This study should be the basis for further evaluations of long-term efficacy and safety of the use of cannabinoids in PD patients.
Collapse
Affiliation(s)
- Marina Peball
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Mario Werkmann
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Philipp Ellmerer
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raphaela Stolz
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Dora Valent
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Hans-Günther Knaus
- Department for Medical Genetics, Molecular and Clinical Pharmacology, Innsbruck Medical University, Peter-Mayr Straße 1, 6020, Innsbruck, Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics, Innsbruck Medical University, Schöpfstraße 41/1, 6020, Innsbruck, Austria
| | - Atbin Djamshidian
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria.
| |
Collapse
|
10
|
Stoessl AJ. Challenges and unfulfilled promises in Parkinson's disease. Lancet Neurol 2018; 16:866-867. [PMID: 29029841 DOI: 10.1016/s1474-4422(17)30334-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 09/19/2017] [Indexed: 12/16/2022]
Affiliation(s)
- A Jon Stoessl
- Pacific Parkinson's Research Centre, Division of Neurology and Djavad Mowafaghian Centre for Brain Health, University of British Columbia and Vancouver Coastal Health, Vancouver, BC V6T 1Z3, Canada.
| |
Collapse
|
11
|
Lang AE, Espay AJ. Disease Modification in Parkinson's Disease: Current Approaches, Challenges, and Future Considerations. Mov Disord 2018; 33:660-677. [DOI: 10.1002/mds.27360] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 02/04/2018] [Accepted: 02/07/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Anthony E. Lang
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology; University of Toronto; Toronto Ontario Canada
| | - Alberto J. Espay
- UC Gardner Neuroscience Institute and Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| |
Collapse
|
12
|
Brundin P, Dave KD, Kordower JH. Therapeutic approaches to target alpha-synuclein pathology. Exp Neurol 2017; 298:225-235. [PMID: 28987463 DOI: 10.1016/j.expneurol.2017.10.003] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 01/09/2023]
Abstract
Starting two decades ago with the discoveries of genetic links between alpha-synuclein and Parkinson's disease risk and the identification of aggregated alpha-synuclein as the main protein constituent of Lewy pathology, alpha-synuclein has emerged as the major therapeutic target in Parkinson's disease and related synucleinopathies. Following the suggestion that alpha-synuclein pathology gradually spreads through the nervous system following a stereotypic pattern and the discovery that aggregated forms of alpha-synuclein can propagate pathology from one cell to another, and thereby probably aggravate existing deficits as well as generate additional symptoms, the idea that alpha-synuclein is a viable therapeutic target gained further support. In this review we describe current challenges and possibilities with alpha-synuclein as a therapeutic target. We briefly highlight gaps in the knowledge of the role of alpha-synuclein in disease, and propose that a deeper understanding of the pathobiology of alpha-synuclein can lead to improved therapeutic strategies. We describe several treatment approaches that are currently being tested in advanced animal experiments or already are in clinical trials. We have divided them into approaches that reduce alpha-synuclein production; inhibit alpha-synuclein aggregation inside cells; promote its degradation either inside or outside cells; and reduce its uptake by neighbouring cells following release from already affected neurons. Finally, we briefly discuss challenges related to the clinical testing of alpha-synuclein therapies, for example difficulties in monitoring target engagement and the need for relatively large trials of long duration. We conclude that alpha-synuclein remains one of the most compelling therapeutic targets for Parkinson's disease, and related synucleinopathies, and that the multitude of approaches being tested provides hope for the future.
Collapse
Affiliation(s)
- Patrik Brundin
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI 49503, USA.
| | - Kuldip D Dave
- The Michael J Fox Foundation, New York, NY 10017, USA
| | - Jeffrey H Kordower
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI 49503, USA; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL 60612, USA
| |
Collapse
|