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Wisch JK, McKay NS, Boerwinkle AH, Kennedy J, Flores S, Handen BL, Christian BT, Head E, Mapstone M, Rafii MS, O'Bryant SE, Price JC, Laymon CM, Krinsky-McHale SJ, Lai F, Rosas HD, Hartley SL, Zaman S, Lott IT, Tudorascu D, Zammit M, Brickman AM, Lee JH, Bird TD, Cohen A, Chrem P, Daniels A, Chhatwal JP, Cruchaga C, Ibanez L, Jucker M, Karch CM, Day GS, Lee JH, Levin J, Llibre-Guerra J, Li Y, Lopera F, Roh JH, Ringman JM, Supnet-Bell C, van Dyck CH, Xiong C, Wang G, Morris JC, McDade E, Bateman RJ, Benzinger TLS, Gordon BA, Ances BM. Comparison of tau spread in people with Down syndrome versus autosomal-dominant Alzheimer's disease: a cross-sectional study. Lancet Neurol 2024; 23:500-510. [PMID: 38631766 PMCID: PMC11209765 DOI: 10.1016/s1474-4422(24)00084-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/01/2024] [Accepted: 02/21/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND In people with genetic forms of Alzheimer's disease, such as in Down syndrome and autosomal-dominant Alzheimer's disease, pathological changes specific to Alzheimer's disease (ie, accumulation of amyloid and tau) occur in the brain at a young age, when comorbidities related to ageing are not present. Studies including these cohorts could, therefore, improve our understanding of the early pathogenesis of Alzheimer's disease and be useful when designing preventive interventions targeted at disease pathology or when planning clinical trials. We compared the magnitude, spatial extent, and temporal ordering of tau spread in people with Down syndrome and autosomal-dominant Alzheimer's disease. METHODS In this cross-sectional observational study, we included participants (aged ≥25 years) from two cohort studies. First, we collected data from the Dominantly Inherited Alzheimer's Network studies (DIAN-OBS and DIAN-TU), which include carriers of autosomal-dominant Alzheimer's disease genetic mutations and non-carrier familial controls recruited in Australia, Europe, and the USA between 2008 and 2022. Second, we collected data from the Alzheimer Biomarkers Consortium-Down Syndrome study, which includes people with Down syndrome and sibling controls recruited from the UK and USA between 2015 and 2021. Controls from the two studies were combined into a single group of familial controls. All participants had completed structural MRI and tau PET (18F-flortaucipir) imaging. We applied Gaussian mixture modelling to identify regions of high tau PET burden and regions with the earliest changes in tau binding for each cohort separately. We estimated regional tau PET burden as a function of cortical amyloid burden for both cohorts. Finally, we compared the temporal pattern of tau PET burden relative to that of amyloid. FINDINGS We included 137 people with Down syndrome (mean age 38·5 years [SD 8·2], 74 [54%] male, and 63 [46%] female), 49 individuals with autosomal-dominant Alzheimer's disease (mean age 43·9 years [11·2], 22 [45%] male, and 27 [55%] female), and 85 familial controls, pooled from across both studies (mean age 41·5 years [12·1], 28 [33%] male, and 57 [67%] female), who satisfied the PET quality-control procedure for tau-PET imaging processing. 134 (98%) people with Down syndrome, 44 (90%) with autosomal-dominant Alzheimer's disease, and 77 (91%) controls also completed an amyloid PET scan within 3 years of tau PET imaging. Spatially, tau PET burden was observed most frequently in subcortical and medial temporal regions in people with Down syndrome, and within the medial temporal lobe in people with autosomal-dominant Alzheimer's disease. Across the brain, people with Down syndrome had greater concentrations of tau for a given level of amyloid compared with people with autosomal-dominant Alzheimer's disease. Temporally, increases in tau were more strongly associated with increases in amyloid for people with Down syndrome compared with autosomal-dominant Alzheimer's disease. INTERPRETATION Although the general progression of amyloid followed by tau is similar for people Down syndrome and people with autosomal-dominant Alzheimer's disease, we found subtle differences in the spatial distribution, timing, and magnitude of the tau burden between these two cohorts. These differences might have important implications; differences in the temporal pattern of tau accumulation might influence the timing of drug administration in clinical trials, whereas differences in the spatial pattern and magnitude of tau burden might affect disease progression. FUNDING None.
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Affiliation(s)
- Julie K Wisch
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA.
| | - Nicole S McKay
- Department of Radiology, Washington University in St Louis, St Louis, MO, USA
| | - Anna H Boerwinkle
- McGovern Medical School, University of Texas in Houston, Houston, TX, USA
| | - James Kennedy
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA
| | - Shaney Flores
- Department of Radiology, Washington University in St Louis, St Louis, MO, USA
| | - Benjamin L Handen
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bradley T Christian
- Department of Medical Physics and Psychiatry, University of Wisconsin-Madison, Madison, WI, USA
| | - Elizabeth Head
- Department of Pathology, Gillespie Neuroscience Research Facility, University of California, Irvine, CA, USA
| | - Mark Mapstone
- Department of Neurology, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Michael S Rafii
- Alzheimer's Therapeutic Research Institute, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Sid E O'Bryant
- Institute for Translational Research Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Julie C Price
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
| | - Charles M Laymon
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sharon J Krinsky-McHale
- Department of Psychology, New York State Institute for Basic Research in Developmental Disabilities, New York, NY, USA
| | - Florence Lai
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
| | - H Diana Rosas
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA; Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
| | - Sigan L Hartley
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Shahid Zaman
- Cambridge Intellectual and Developmental Disabilities Research Group, University of Cambridge, Cambridge, UK
| | - Ira T Lott
- Department of Pediatrics, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Dana Tudorascu
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew Zammit
- Department of Medical Physics and Psychiatry, University of Wisconsin-Madison, Madison, WI, USA
| | - Adam M Brickman
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Joseph H Lee
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA; Department of Epidemiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Thomas D Bird
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Annie Cohen
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patricio Chrem
- Centro de Memoria y Envejecimiento, Buenos Aires, Argentina
| | - Alisha Daniels
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA
| | - Jasmeer P Chhatwal
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
| | - Carlos Cruchaga
- Department of Psychiatry, Washington University in St Louis, St Louis, MO, USA; Hope Center for Neurological Disorders, Washington University in St Louis, St Louis, MO, USA
| | - Laura Ibanez
- Department of Psychiatry, Washington University in St Louis, St Louis, MO, USA
| | - Mathias Jucker
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Celeste M Karch
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA; Department of Psychiatry, Washington University in St Louis, St Louis, MO, USA; German Center for Neurodegenerative Diseases, Tübingen, Germany
| | - Gregory S Day
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jae-Hong Lee
- Department of Neurology, University of Ulsan College of Medicine, Asian Medical Center, Seoul, South Korea
| | - Johannes Levin
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany; German Center for Neurodegenerative Diseases, site Munich, Munich, Germany; Munich Cluster for Systems Neurology, Munich, Germany
| | - Jorge Llibre-Guerra
- Hope Center for Neurological Disorders, Washington University in St Louis, St Louis, MO, USA
| | - Yan Li
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA; Department of Biostatistics, Washington University in St Louis, St Louis, MO, USA
| | - Francisco Lopera
- Grupo de Neurociencias de Antioquia, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Jee Hoon Roh
- Departments of Physiology and Neurology, Korea University College of Medicine, Seoul, South Korea
| | - John M Ringman
- Alzheimer's Therapeutic Research Institute, Keck School of Medicine of USC, Los Angeles, CA, USA
| | | | | | - Chengjie Xiong
- Department of Biostatistics, Washington University in St Louis, St Louis, MO, USA
| | - Guoqiao Wang
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA; Department of Biostatistics, Washington University in St Louis, St Louis, MO, USA
| | - John C Morris
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA
| | - Eric McDade
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA
| | - Randall J Bateman
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA
| | | | - Brian A Gordon
- Department of Radiology, Washington University in St Louis, St Louis, MO, USA
| | - Beau M Ances
- Department of Neurology, Washington University in St Louis, St Louis, MO, USA
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Geerts H, Bergeler S, Walker M, Rose RH, van der Graaf PH. Quantitative systems pharmacology-based exploration of relevant anti-amyloid therapy challenges in clinical practice. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2024; 10:e12474. [PMID: 38774587 PMCID: PMC11106679 DOI: 10.1002/trc2.12474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/16/2024] [Accepted: 03/17/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Addressing practical challenges in clinical practice after the recent approvals of amyloid antibodies in Alzheimer's disease (AD) will benefit more patients. However, generating these answers using clinical trials or real-world evidence is not practical, nor feasible. METHODS Here we use a Quantitative Systems Pharmacology (QSP) computational model of amyloid aggregation dynamics, well validated with clinical data on biomarkers and amyloid-related imaging abnormality-edema (ARIA-E) liability of six amyloid antibodies in clinical trials to explore various clinical practice challenges. RESULTS Treatment duration to reach amyloid negativity ranges from 12 to 44, 16 to 40, and 6 to 20 months for lecanemab, aducanumab, and donanemab, respectively, for baseline central amyloid values between 50 and 200 Centiloids (CL). Changes in plasma cerebrospinal fluid Aβ42 and the plasma Aβ42/ Aβ40 ratio-fluid biomarkers to detect central amyloid negativity-is greater for lecanemab than for aducanumab and donanemab, indicating that these fluid amyloid biomarkers are only suitable for lecanemab. After reaching amyloid negativity an optimal maintenance schedule consists of a 24-month, 48-month and 64-month interval for 10 mg/kg (mpk) lecanemab, 10 mpk aducanumab, and 20 mpk donanemab, respectively, to keep central amyloid negative for 10 years. Cumulative ARIA-E liability could be reduced to almost half by introducing a drug holiday in the first months. For patients experiencing ARIA-E, restarting treatment with a conservative titration strategy resulted in an additional delay ranging between 3 and 4 months (donanemab), 5 months (lecanemab), and up to 7 months (aducanumab) for reaching amyloid negativity, depending upon the timing of the incident. Clinical trial designs for Down syndrome patients suggested the same rank order for central amyloid reduction, but higher ARIA-E liability especially for donanemab, which can be significantly mitigated by adopting a longer titration period. DISCUSSION This QSP platform could support clinical practice challenges to optimize real-world treatment paradigms for new and existing amyloid drugs.
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Affiliation(s)
- Hugo Geerts
- Certara Predictive TechnologiesBerwynPennsylvaniaUSA
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Sukreet S, Rafii MS, Rissman RA. From understanding to action: Exploring molecular connections of Down syndrome to Alzheimer's disease for targeted therapeutic approach. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2024; 16:e12580. [PMID: 38623383 PMCID: PMC11016820 DOI: 10.1002/dad2.12580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 03/05/2024] [Accepted: 03/08/2024] [Indexed: 04/17/2024]
Abstract
Down syndrome (DS) is caused by a third copy of chromosome 21. Alzheimer's disease (AD) is a neurodegenerative condition characterized by the deposition of amyloid-beta (Aβ) plaques and neurofibrillary tangles in the brain. Both disorders have elevated Aβ, tau, dysregulated immune response, and inflammation. In people with DS, Hsa21 genes like APP and DYRK1A are overexpressed, causing an accumulation of amyloid and neurofibrillary tangles, and potentially contributing to an increased risk of AD. As a result, people with DS are a key demographic for research into AD therapeutics and prevention. The molecular links between DS and AD shed insights into the underlying causes of both diseases and highlight potential therapeutic targets. Also, using biomarkers for early diagnosis and treatment monitoring is an active area of research, and genetic screening for high-risk individuals may enable earlier intervention. Finally, the fundamental mechanistic parallels between DS and AD emphasize the necessity for continued research into effective treatments and prevention measures for DS patients at risk for AD. Genetic screening with customized therapy approaches may help the DS population in current clinical studies and future biomarkers.
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Affiliation(s)
- Sonal Sukreet
- Department of NeurosciencesUniversity of California‐San DiegoLa JollaCaliforniaUSA
| | - Michael S. Rafii
- Department of Neurology, Alzheimer's Therapeutic Research InstituteKeck School of Medicine of the University of Southern CaliforniaSan DiegoCaliforniaUSA
| | - Robert A. Rissman
- Department of NeurosciencesUniversity of California‐San DiegoLa JollaCaliforniaUSA
- Department Physiology and Neuroscience, Alzheimer’s Therapeutic Research InstituteKeck School of Medicine of the University of Southern CaliforniaSan DiegoCaliforniaUSA
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Sokol DK, Lahiri DK. Alzheimer's drugs, APPlication for Down syndrome? Ageing Res Rev 2024; 96:102281. [PMID: 38513771 DOI: 10.1016/j.arr.2024.102281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/12/2024] [Accepted: 03/18/2024] [Indexed: 03/23/2024]
Abstract
Accumulation of the amyloid β (Aβ) peptide, derived from Aβ precursor protein (APP), is a trait of Down syndrome (DS), as is early development of dementia that resembles Alzheimer's disease (AD). Treatments for this AD in DS simply do not. New drug therapies for AD, e.g., Lecanemab, are monoclonal antibodies designed to clear amyloid plaques composed of Aβ. The increasingly real ability to target and dispose of Aβ favors the use of these drugs in individuals with AD in DS, and, perhaps as earlier intervention for cognitive impairment. We present pertinent similarities between DS and AD in adult DS subjects, discuss challenges to target APP metabolites, and suggest that recently developed antibody treatments against Aβ may be worth investigating to treat AD in DS.
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Affiliation(s)
- Deborah K Sokol
- Department of Neurology, Section Pediatrics, Indiana University of Medicine, Riley Hospital, 575 Riley Hospital Drive, Indianapolis, IN 46202, USA
| | - Debomoy K Lahiri
- Department of Psychiatry, 320 West 15th St, Indianapolis, IN 46202, USA; Department of Medical and Molecular Genetics, 320 West 15th St, Indianapolis, IN 46202, USA; Stark Neurosciences Research Institute, 320 West 15th St, Indianapolis, IN 46202, USA; Indiana Alzheimer's Disease Research Center, 320 West 15th St, Indianapolis, IN 46202, USA.
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Gharat R, Dixit G, Khambete M, Prabhu A. Targets, trials and tribulations in Alzheimer therapeutics. Eur J Pharmacol 2024; 962:176230. [PMID: 38042464 DOI: 10.1016/j.ejphar.2023.176230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 12/04/2023]
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by abnormal accumulation of extracellular amyloid beta senile plaques and intracellular neurofibrillary tangles in the parts of the brain responsible for cognition. The therapeutic burden for the management of AD relies solely on cholinesterase inhibitors that provide only symptomatic relief. The urgent need for disease-modifying drugs has resulted in intensive research in this domain, which has led to better understanding of the disease pathology and identification of a plethora of new pathological targets. Currently, there are over a hundred and seventy clinical trials exploring disease modification, cognitive enhancement, and reduction of neuro-psychiatric complications. However, the path to developing safe and efficacious AD therapeutics has not been without challenges. Several clinical trials have been terminated in advanced stages due to lack of therapeutic translation or increased incidence of adverse events. This review presents an in-depth look at the various therapeutic targets of AD and the lessons learnt during their clinical assessment. Comprehensive understanding of the implication of modulating various aspects of Alzheimer brain pathology is crucial for development of drugs with potential to halt disease progression in Alzheimer therapeutics.
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Affiliation(s)
- Ruchita Gharat
- SVKM's Dr. Bhanuben Nanavati College of Pharmacy, VM Road, Vile Parle (West), Mumbai, 400056, Maharashtra, India
| | - Gargi Dixit
- SVKM's Dr. Bhanuben Nanavati College of Pharmacy, VM Road, Vile Parle (West), Mumbai, 400056, Maharashtra, India
| | - Mihir Khambete
- Department of Chemistry, Yale University, New Haven, CT, USA
| | - Arati Prabhu
- SVKM's Dr. Bhanuben Nanavati College of Pharmacy, VM Road, Vile Parle (West), Mumbai, 400056, Maharashtra, India.
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Rafii MS, Aisen PS. Detection and treatment of Alzheimer's disease in its preclinical stage. NATURE AGING 2023; 3:520-531. [PMID: 37202518 PMCID: PMC11110912 DOI: 10.1038/s43587-023-00410-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/29/2023] [Indexed: 05/20/2023]
Abstract
Longitudinal multimodal biomarker studies reveal that the continuum of Alzheimer's disease (AD) includes a long latent phase, referred to as preclinical AD, which precedes the onset of symptoms by decades. Treatment during the preclinical AD phase offers an optimal opportunity for slowing the progression of disease. However, trial design in this population is complex. In this Review, we discuss the recent advances in accurate plasma measurements, new recruitment approaches, sensitive cognitive instruments and self-reported outcomes that have facilitated the successful launch of multiple phase 3 trials for preclinical AD. The recent success of anti-amyloid immunotherapy trials in symptomatic AD has increased the enthusiasm for testing this strategy at the earliest feasible stage. We provide an outlook for standard screening of amyloid accumulation at the preclinical stage in clinically normal individuals, during which effective therapy to delay or prevent cognitive decline can be initiated.
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Affiliation(s)
- Michael S Rafii
- Alzheimer's Therapeutic Research Institute, Keck School of Medicine University of Southern California, Los Angeles, CA, USA.
| | - Paul S Aisen
- Alzheimer's Therapeutic Research Institute, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
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Elangovan A, Babu HWS, Iyer M, Gopalakrishnan AV, Vellingiri B. Untangle the mystery behind DS-associated AD - Is APP the main protagonist? Ageing Res Rev 2023; 87:101930. [PMID: 37031726 DOI: 10.1016/j.arr.2023.101930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/11/2023]
Abstract
Amyloid precursor protein profusion in Trisomy 21, also called Down Syndrome (DS), is rooted in the genetic determination of Alzheimer's disease (AD). With the recent development in patient care, the life expectancy of DS patients has gradually increased, leading to the high prospect of AD development, consequently leading to the development of plaques of amyloid proteins and neurofibrillary tangles made of tau by the fourth decade of the patient leading to dementia. The altered gene expression resulted in cellular dysfunction due to impairment of autophagy, mitochondrial and lysosomal dysfunction, and copy number variation controlled by the additional genes in Trisomy 21. The cognitive impairment and mechanistic insights underlying DS-AD conditions have been reviewed in this article. Some recent findings regarding biomarkers and therapeutics of DS-AD conditions were highlighted in this review.
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Affiliation(s)
- Ajay Elangovan
- Stem cell and Regenerative Medicine/ Translational Research, Department of Zoology, School of Basic Sciences, Central University of Punjab, Bathinda 151401, Punjab, India; Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore 641 046, Tamil Nadu, India
| | - Harysh Winster Suresh Babu
- Stem cell and Regenerative Medicine/ Translational Research, Department of Zoology, School of Basic Sciences, Central University of Punjab, Bathinda 151401, Punjab, India; Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore 641 046, Tamil Nadu, India
| | - Mahalaxmi Iyer
- Department of Biotechnology, Karpagam Academy of Higher Education (Deemed to be University), Coimbatore-641021, India
| | | | - Balachandar Vellingiri
- Stem cell and Regenerative Medicine/ Translational Research, Department of Zoology, School of Basic Sciences, Central University of Punjab, Bathinda 151401, Punjab, India; Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore 641 046, Tamil Nadu, India.
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Cummings J, Apostolova L, Rabinovici GD, Atri A, Aisen P, Greenberg S, Hendrix S, Selkoe D, Weiner M, Petersen RC, Salloway S. Lecanemab: Appropriate Use Recommendations. J Prev Alzheimers Dis 2023; 10:362-377. [PMID: 37357276 PMCID: PMC10313141 DOI: 10.14283/jpad.2023.30] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
Lecanemab (Leqembi®) is approved in the United States for the treatment of Alzheimer's disease (AD) to be initiated in early AD (mild cognitive impairment [MCI] due to AD or mild AD dementia) with confirmed brain amyloid pathology. Appropriate Use Recommendations (AURs) are intended to help guide the introduction of new therapies into real-world clinical practice. Community dwelling patients with AD differ from those participating in clinical trials. Administration of lecanemab at clinical trial sites by individuals experienced with monoclonal antibody therapy also differs from the community clinic-based administration of lecanemab. These AURs use clinical trial data as well as research and care information regarding AD to help clinicians administer lecanemab with optimal safety and opportunity for effectiveness. Safety and efficacy of lecanemab are known only for patients like those participating in the phase 2 and phase 3 lecanemab trials, and these AURs adhere closely to the inclusion and exclusion criteria of the trials. Adverse events may occur with lecanemab including amyloid related imaging abnormalities (ARIA) and infusion reactions. Monitoring guidelines for these events are detailed in this AUR. Most ARIA with lecanemab is asymptomatic, but a few cases are serious or, very rarely, fatal. Microhemorrhages and rare macrohemorrhages may occur in patients receiving lecanemab. Anticoagulation increases the risk of hemorrhage, and the AUR recommends that patients requiring anticoagulants not receive lecanemab until more data regarding this interaction are available. Patients who are apolipoprotein E ε4 (APOE4) gene carriers, especially APOE4 homozygotes, are at higher risk for ARIA, and the AUR recommends APOE genotyping to better inform risk discussions with patients who are lecanemab candidates. Clinician and institutional preparedness are mandatory for use of lecanemab, and protocols for management of serious events should be developed and implemented. Communication between clinicians and therapy candidates or those on therapy is a key element of good clinical practice for the use of lecanemab. Patients and their care partners must understand the potential benefits, the potential harms, and the monitoring requirements for treatment with this agent. Culture-specific communication and building of trust between clinicians and patients are the foundation for successful use of lecanemab.
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Affiliation(s)
- J Cummings
- Jeffrey Cummings, MD, ScD, 1380 Opal Valley Street, Henderson, NV 89052, USA, , T: 702-902-3939
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Ganguly BB, Kadam NN. Therapeutics for mitochondrial dysfunction-linked diseases in Down syndrome. Mitochondrion 2023; 68:25-43. [PMID: 36371073 DOI: 10.1016/j.mito.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
Genome-wide deregulation contributes to mitochondrial dysfunction and impairment in oxidative phosphorylation (OXPHOS) mechanism resulting in oxidative stress, increased production of reactive oxygen species (ROS) and cell death in individuals with Down syndrome (DS). The cells, which require more energy, such as muscles, brain and heart are greatly affected. Impairment in mitochondrial network has a direct link with patho-mechanism at cellular and systemic levels at the backdrop of generalized metabolic perturbations in individuals with DS. Myriads of clinico-phenotypic features, including intellectual disability, early aging and neurodegeneration, and Alzheimer disease (AD)-related dementia are inevitable in DS-population where mitochondrial dysfunctions play the central role. Collectively, the mitochondrial abnormalities and altered energy metabolism perturbs several signaling pathways, particularly related to neurogenesis, which are directly associated with cognitive development and early onset of AD in individuals with DS. Therefore, therapeutic challenges for amelioration of the mitochondrial defects were perceived to improve the quality of life of the DS population. A number of pharmacologically active natural compounds such as polyphenols, antioxidants and flavonoids have shown convincing outcome for reversal of the dysfunctional mitochondrial network and oxidative metabolism, and improvement in intellectual skill in mouse models of DS and humans with DS.
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Affiliation(s)
- Bani Bandana Ganguly
- MGM New Bombay Hospital and MGM Institute of Health Sciences, Navi Mumbai, India.
| | - Nitin N Kadam
- MGM New Bombay Hospital and MGM Institute of Health Sciences, Navi Mumbai, India
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Fleming V, Hom CL, Clare ICH, Hurd-Thomas SL, Krinsky-McHale S, Handen B, Hartley SL. Cognitive outcome measures for tracking Alzheimer's disease in Down syndrome. INTERNATIONAL REVIEW OF RESEARCH IN DEVELOPMENTAL DISABILITIES 2022; 62:227-263. [PMID: 37396708 PMCID: PMC10312212 DOI: 10.1016/bs.irrdd.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Down syndrome (DS) is now viewed as a genetic type of Alzheimer's disease (AD), given the near-universal presence of AD pathology in middle adulthood and the elevated risk for developing clinical AD in DS. As the field of DS prepares for AD clinical intervention trials, there is a strong need to identify cognitive measures that are specific and sensitive to the transition from being cognitively stable to the prodromal (e.g., Mild Cognitive Impairment-Down syndrome) and clinical AD (e.g., Dementia) stages of the disease in DS. It is also important to determine cognitive measures that map onto biomarkers of early AD pathology during the transition from the preclinical to the prodromal stage of the disease, as this transition period is likely to be targeted and tracked in AD clinical trials. The present chapter discusses the current state of research on cognitive measures that could be used to screen/select study participants and as potential outcome measures in future AD clinical trials with adults with DS. In this chapter, we also identify key challenges that need to be overcome and questions that need to be addressed by the DS field as it prepares for AD clinical trials in the coming years.
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Affiliation(s)
- Victoria Fleming
- Waisman Center, University of Wisconsin-Madison, Madison, WI, United States
- School of Human Ecology, University of Wisconsin-Madison, Madison, WI, United States
| | - Christy L Hom
- Department of Psychiatry and Human Behavior, University of California, Irvine School of Medicine, Orange, CA, United States
| | - Isabel C H Clare
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | | | - Sharon Krinsky-McHale
- New York State Institute for Basic Research in Developmental Disabilities, Staten Island, NY, United States
| | - Benjamin Handen
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sigan L Hartley
- Waisman Center, University of Wisconsin-Madison, Madison, WI, United States
- School of Human Ecology, University of Wisconsin-Madison, Madison, WI, United States
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Aisen PS, Jimenez-Maggiora GA, Rafii MS, Walter S, Raman R. Early-stage Alzheimer disease: getting trial-ready. Nat Rev Neurol 2022; 18:389-399. [PMID: 35379951 PMCID: PMC8978175 DOI: 10.1038/s41582-022-00645-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/15/2022]
Abstract
Slowing the progression of Alzheimer disease (AD) might be the greatest unmet medical need of our time. Although one AD therapeutic has received a controversial accelerated approval from the FDA, more effective and accessible therapies are urgently needed. Consensus is growing that for meaningful disease modification in AD, therapeutic intervention must be initiated at very early (preclinical or prodromal) stages of the disease. Although the methods for such early-stage clinical trials have been developed, identification and recruitment of the required asymptomatic or minimally symptomatic study participants takes many years and requires substantial funds. As an example, in the Anti-Amyloid Treatment in Asymptomatic Alzheimer’s Disease Trial (the first phase III trial to be performed in preclinical AD), 3.5 years and more than 5,900 screens were required to recruit and randomize 1,169 participants. A new clinical trials infrastructure is required to increase the efficiency of recruitment and accelerate therapeutic progress. Collaborations in North America, Europe and Asia are now addressing this need by establishing trial-ready cohorts of individuals with preclinical and prodromal AD. These collaborations are employing innovative methods to engage the target population, assess risk of brain amyloid accumulation, select participants for biomarker studies and determine eligibility for trials. In the future, these programmes could provide effective tools for pursuing the primary prevention of AD. Here, we review the lessons learned from the AD trial-ready cohorts that have been established to date, with the aim of informing ongoing and future efforts towards efficient, cost-effective trial recruitment. Consensus is growing that intervention in the very early stages of Alzheimer disease is necessary for disease modification. Here, the authors discuss the challenges of recruiting asymptomatic or mildly symptomatic participants for clinical trials, focusing on ‘trial-ready’ cohorts as a potential solution. Trial-ready cohorts are an effective strategy for the identification of participants eligible for clinical trials in early-stage Alzheimer disease (AD). Building these cohorts requires considerable planning and technological infrastructure to facilitate recruitment, remote longitudinal assessment, data management and data storage. Trial-ready cohorts exist for genetically determined populations at risk of AD, such as those with familial AD and Down syndrome; the longitudinal data from these cohorts is improving our understanding of the disease progression in early stages, informing clinical trial design and accelerating recruitment to intervention studies. So far, the challenges experienced by trial-ready cohorts for early-stage AD have included difficulties recruiting an ethnically and racially representative cohort; and for online cohorts, difficulty retaining participants. The results of ongoing work will reveal the success of strategies to improve cohort diversity and retention, and the rates of referral to clinical trials.
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Vukicevic M, Fiorini E, Siegert S, Carpintero R, Rincon-Restrepo M, Lopez-Deber P, Piot N, Ayer M, Rentero I, Babolin C, Bravo-Veyrat S, Giriens V, Morici C, Beuzelin M, Gesbert A, Rivot S, Depretti S, Donati P, Streffer J, Pfeifer A, Kosco-Vilbois MH. OUP accepted manuscript. Brain Commun 2022; 4:fcac022. [PMID: 35479516 PMCID: PMC9037369 DOI: 10.1093/braincomms/fcac022] [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: 11/22/2021] [Revised: 11/22/2021] [Accepted: 02/01/2022] [Indexed: 11/14/2022] Open
Abstract
Pyroglutamate amyloid beta3–42 (pGlu-Abeta3–42), a highly
amyloidogenic and neurotoxic form of Abeta, is N-terminally truncated to form a
pyroglutamate and has recently been proposed as a key target for immunotherapy.
Optimized ACI-24, a vaccine in development for the treatment and prevention of
Alzheimer’s disease, focuses the antibody response on the first 15
N-terminal amino acids of Abeta (Abeta1–15). Importantly, clinical data
with an initial version of ACI-24 incorporating Abeta1–15, established
the vaccine’s safety and tolerability with evidence of immunogenicity. To
explore optimized ACI-24’s capacity to generate antibodies to
pGlu-Abeta3–42, pre-clinical studies were carried out. Vaccinating mice
and non-human primates demonstrated that optimized ACI-24 was well-tolerated and
induced an antibody response against Abeta1–42 as expected, as well as
high titres of IgG reactive with pyroGlu-Abeta. Epitope mapping of the
polyclonal response confirmed these findings revealing broad coverage of
epitopes particularly for Abeta peptides mimicking where cleavage occurs to form
pGlu-Abeta3–42. These data are in striking contrast to results obtained
with other clinically tested Abeta targeting vaccines which generated restricted
and limited antibody diversity. Taken together, our findings demonstrate that
optimized ACI-24 vaccination represents a breakthrough to provide a safe immune
response with a broader Abeta sequence recognition compared to previously tested
vaccines, creating binders to pathogenic forms of Abeta important in
pathogenesis including pGlu-Abeta3–42.
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Affiliation(s)
| | | | | | | | | | | | - N. Piot
- AC Immune SA, Lausanne, Switzerland
| | - M. Ayer
- AC Immune SA, Lausanne, Switzerland
| | | | | | | | | | | | | | | | - S. Rivot
- AC Immune SA, Lausanne, Switzerland
| | | | | | - J. Streffer
- AC Immune SA, Lausanne, Switzerland
- Biomedical Sciences, University of
Antwerp, Antwerp, Belgium
| | | | - M. H. Kosco-Vilbois
- AC Immune SA, Lausanne, Switzerland
- Correspondence to: M. Kosco-Vilbois AC Immune, AC Immune
SA EPFL Innovation Park, Building B CH-1015 Lausanne, Switzerland E-mail:
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Jeremic D, Jiménez-Díaz L, Navarro-López JD. Past, present and future of therapeutic strategies against amyloid-β peptides in Alzheimer's disease: a systematic review. Ageing Res Rev 2021; 72:101496. [PMID: 34687956 DOI: 10.1016/j.arr.2021.101496] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/30/2021] [Accepted: 10/18/2021] [Indexed: 12/12/2022]
Abstract
Alzheimer's disease (AD) is the most prevalent neurodegenerative disease in ageing, affecting around 46 million people worldwide but few treatments are currently available. The etiology of AD is still puzzling, and new drugs development and clinical trials have high failure rates. Urgent outline of an integral (multi-target) and effective treatment of AD is needed. Accumulation of amyloid-β (Aβ) peptides is considered one of the fundamental neuropathological pillars of the disease, and its dyshomeostasis has shown a crucial role in AD onset. Therefore, many amyloid-targeted therapies have been investigated. Here, we will systematically review recent (from 2014) investigational, follow-up and review studies focused on anti-amyloid strategies to summarize and analyze their current clinical potential. Combination of anti-Aβ therapies with new developing early detection biomarkers and other therapeutic agents acting on early functional AD changes will be highlighted in this review. Near-term approval seems likely for several drugs acting against Aβ, with recent FDA approval of a monoclonal anti-Aβ oligomers antibody -aducanumab- raising hopes and controversies. We conclude that, development of oligomer-epitope specific Aβ treatment and implementation of multiple improved biomarkers and risk prediction methods allowing early detection, together with therapies acting on other factors such as hyperexcitability in early AD, could be the key to slowing this global pandemic.
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