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Raghavan S, Lesnick TG, Castillo AM, Reid RI, Fought AJ, Thostenson KB, Johnson Sparrman KL, Gehrking TL, Gehrking JA, Sletten DM, Low PA, Singer W, Vemuri P. White Matter Abnormalities Track Disease Progression in Multiple System Atrophy. Mov Disord Clin Pract 2024. [PMID: 38923361 DOI: 10.1002/mdc3.14147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/16/2024] [Accepted: 05/26/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND White matter (WM) abnormalities have been implicated in clinically relevant functional decline in multiple system atrophy (MSA). OBJECTIVE To identify the WM and gray matter (GM) abnormalities in MSA and assess the utility of longitudinal structural and diffusion changes as surrogate markers for tracking disease progression in MSA. METHODS Twenty-seven participants with early MSA [15 with clinically predominant cerebellar (MSA-C) and 12 with clinically predominant parkinsonian features (MSA-P)] and 14 controls were enrolled as a part of our prospective, longitudinal study of synucleinopathies. Using structural magnetic resonance imaging (MRI) and diffusion MRI (diffusion tensor and neurite orientation and dispersion density imaging), we analyzed whole and regional brain changes in these participants. We also evaluated temporal imaging trajectories based on up to three annual follow-up scans and assessed the impact of baseline diagnosis on these imaging biomarkers using mixed-effect models. RESULTS MSA patients exhibited more widespread WM changes than GM, particularly in the cerebellum and brainstem, with greater severity in MSA-C. Structural and diffusion measures in the cerebellum WM and brainstem deteriorated with disease progression. Rates of progression of these abnormalities were similar in both MSA subtypes, reflecting increasing overlap of clinical features over time. CONCLUSION WM abnormalities are core features of MSA disease progression and advance at similar rates in clinical MSA subtypes. Multimodal MRI imaging reveals novel insights into the distribution and pattern of brain abnormalities and their progression in MSA. Selected structural and diffusion measures may be useful for tracking disease progression in MSA clinical trials.
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Affiliation(s)
| | - Timothy G Lesnick
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Anna M Castillo
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Robert I Reid
- Department of Information Technology, Mayo Clinic, Rochester, MN, USA
| | - Angela J Fought
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Bendetowicz D, Fabbri M, Sirna F, Fernagut PO, Foubert-Samier A, Saulnier T, Le Traon AP, Proust-Lima C, Rascol O, Meissner WG. Recent Advances in Clinical Trials in Multiple System Atrophy. Curr Neurol Neurosci Rep 2024; 24:95-112. [PMID: 38416311 DOI: 10.1007/s11910-024-01335-0] [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] [Accepted: 02/13/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE OF REVIEW This review summarizes previous and ongoing neuroprotection trials in multiple system atrophy (MSA), a rare and fatal neurodegenerative disease characterized by parkinsonism, cerebellar, and autonomic dysfunction. It also describes the preclinical therapeutic pipeline and provides some considerations relevant to successfully conducting clinical trials in MSA, i.e., diagnosis, endpoints, and trial design. RECENT FINDINGS Over 30 compounds have been tested in clinical trials in MSA. While this illustrates a strong treatment pipeline, only two have reached their primary endpoint. Ongoing clinical trials primarily focus on targeting α-synuclein, the neuropathological hallmark of MSA being α-synuclein-bearing glial cytoplasmic inclusions. The mostly negative trial outcomes highlight the importance of better understanding underlying disease mechanisms and improving preclinical models. Together with efforts to refine clinical measurement tools, innovative statistical methods, and developments in biomarker research, this will enhance the design of future neuroprotection trials in MSA and the likelihood of positive outcomes.
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Affiliation(s)
- David Bendetowicz
- Univ. Bordeaux, CNRS, IMN, UMR5293, Bordeaux, France.
- CHU Bordeaux, Service de Neurologie des Maladies Neurodégénératives, IMNc, CRMR AMS, NS-Park/FCRIN Network, Bordeaux, France.
| | - Margherita Fabbri
- MSA French Reference Center, Univ. Hospital Toulouse, Toulouse, France
- Univ. Toulouse, CIC-1436, Departments of Clinical Pharmacology and Neurosciences, NeuroToul COEN Center, NS-Park/FCRIN Network, Toulouse University Hospital, Inserm, U1048/1214, Toulouse, France
| | - Federico Sirna
- Univ. Bordeaux, INSERM, BPH, U1219, IPSED, Bordeaux, France
| | - Pierre-Olivier Fernagut
- Université de Poitiers, Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM UMR-S 1084, Poitiers, France
| | - Alexandra Foubert-Samier
- Univ. Bordeaux, CNRS, IMN, UMR5293, Bordeaux, France
- CHU Bordeaux, Service de Neurologie des Maladies Neurodégénératives, IMNc, CRMR AMS, NS-Park/FCRIN Network, Bordeaux, France
- Univ. Bordeaux, INSERM, BPH, U1219, IPSED, Bordeaux, France
| | | | - Anne Pavy Le Traon
- MSA French Reference Center, Univ. Hospital Toulouse, Toulouse, France
- Univ. Toulouse, CIC-1436, Departments of Clinical Pharmacology and Neurosciences, NeuroToul COEN Center, NS-Park/FCRIN Network, Toulouse University Hospital, Inserm, U1048/1214, Toulouse, France
| | | | - Olivier Rascol
- MSA French Reference Center, Univ. Hospital Toulouse, Toulouse, France
- Univ. Toulouse, CIC-1436, Departments of Clinical Pharmacology and Neurosciences, NeuroToul COEN Center, NS-Park/FCRIN Network, Toulouse University Hospital, Inserm, U1048/1214, Toulouse, France
| | - Wassilios G Meissner
- Univ. Bordeaux, CNRS, IMN, UMR5293, Bordeaux, France
- CHU Bordeaux, Service de Neurologie des Maladies Neurodégénératives, IMNc, CRMR AMS, NS-Park/FCRIN Network, Bordeaux, France
- Department of Medicine, University of Otago, Christchurch, and New Zealand Brain Research Institute, Christchurch, New Zealand
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Ndayisaba A, Pitaro AT, Willett AS, Jones KA, de Gusmao CM, Olsen AL, Kim J, Rissanen E, Woods JK, Srinivasan SR, Nagy A, Nagy A, Mesidor M, Cicero S, Patel V, Oakley DH, Tuncali I, Taglieri-Noble K, Clark EC, Paulson J, Krolewski RC, Ho GP, Hung AY, Wills AM, Hayes MT, Macmore JP, Warren L, Bower PG, Langer CB, Kellerman LR, Humphreys CW, Glanz BI, Dielubanza EJ, Frosch MP, Freeman RL, Gibbons CH, Stefanova N, Chitnis T, Weiner HL, Scherzer CR, Scholz SW, Vuzman D, Cox LM, Wenning G, Schmahmann JD, Gupta AS, Novak P, Young GS, Feany MB, Singhal T, Khurana V. Clinical Trial-Ready Patient Cohorts for Multiple System Atrophy: Coupling Biospecimen and iPSC Banking to Longitudinal Deep-Phenotyping. CEREBELLUM (LONDON, ENGLAND) 2024; 23:31-51. [PMID: 36190676 PMCID: PMC9527378 DOI: 10.1007/s12311-022-01471-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/30/2022]
Abstract
Multiple system atrophy (MSA) is a fatal neurodegenerative disease of unknown etiology characterized by widespread aggregation of the protein alpha-synuclein in neurons and glia. Its orphan status, biological relationship to Parkinson's disease (PD), and rapid progression have sparked interest in drug development. One significant obstacle to therapeutics is disease heterogeneity. Here, we share our process of developing a clinical trial-ready cohort of MSA patients (69 patients in 2 years) within an outpatient clinical setting, and recruiting 20 of these patients into a longitudinal "n-of-few" clinical trial paradigm. First, we deeply phenotype our patients with clinical scales (UMSARS, BARS, MoCA, NMSS, and UPSIT) and tests designed to establish early differential diagnosis (including volumetric MRI, FDG-PET, MIBG scan, polysomnography, genetic testing, autonomic function tests, skin biopsy) or disease activity (PBR06-TSPO). Second, we longitudinally collect biospecimens (blood, CSF, stool) and clinical, biometric, and imaging data to generate antecedent disease-progression scores. Third, in our Mass General Brigham SCiN study (stem cells in neurodegeneration), we generate induced pluripotent stem cell (iPSC) models from our patients, matched to biospecimens, including postmortem brain. We present 38 iPSC lines derived from MSA patients and relevant disease controls (spinocerebellar ataxia and PD, including alpha-synuclein triplication cases), 22 matched to whole-genome sequenced postmortem brain. iPSC models may facilitate matching patients to appropriate therapies, particularly in heterogeneous diseases for which patient-specific biology may elude animal models. We anticipate that deeply phenotyped and genotyped patient cohorts matched to cellular models will increase the likelihood of success in clinical trials for MSA.
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Affiliation(s)
- Alain Ndayisaba
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
- Division of Clinical Neurobiology, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Ariana T Pitaro
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Andrew S Willett
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Kristie A Jones
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Claudio Melo de Gusmao
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Abby L Olsen
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Jisoo Kim
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Eero Rissanen
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Jared K Woods
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Sharan R Srinivasan
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI , 48103, USA
| | - Anna Nagy
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Amanda Nagy
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Merlyne Mesidor
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Steven Cicero
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Viharkumar Patel
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Derek H Oakley
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Idil Tuncali
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Katherine Taglieri-Noble
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Emily C Clark
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Jordan Paulson
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Richard C Krolewski
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Gary P Ho
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Albert Y Hung
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Anne-Marie Wills
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Michael T Hayes
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Jason P Macmore
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | | | - Pamela G Bower
- The Multiple System Atrophy Coalition, Inc., 7918 Jones Branch Drive, Suite 300, McLean, VA, 22102, USA
| | - Carol B Langer
- The Multiple System Atrophy Coalition, Inc., 7918 Jones Branch Drive, Suite 300, McLean, VA, 22102, USA
| | - Lawrence R Kellerman
- The Multiple System Atrophy Coalition, Inc., 7918 Jones Branch Drive, Suite 300, McLean, VA, 22102, USA
| | - Christopher W Humphreys
- Department of Pulmonary, Sleep and Critical Care Medicine, Salem Hospital, MassGeneral Brigham, Salem, MA, 01970, USA
| | - Bonnie I Glanz
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Elodi J Dielubanza
- Department of Urology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Matthew P Frosch
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Roy L Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
| | - Christopher H Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
| | - Nadia Stefanova
- Division of Clinical Neurobiology, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Tanuja Chitnis
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Howard L Weiner
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Clemens R Scherzer
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Sonja W Scholz
- Laboratory of Neurogenetics, Disorders and Stroke, National Institute of Neurological, National Institute of Neurological Disorders and Stroke, Bethesda, MD, 20892, USA
- Department of Neurology, Johns Hopkins University Medical Center, Baltimore, MD, 21287, USA
| | - Dana Vuzman
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Laura M Cox
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Gregor Wenning
- Division of Clinical Neurobiology, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Jeremy D Schmahmann
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Anoopum S Gupta
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Peter Novak
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Geoffrey S Young
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Mel B Feany
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Tarun Singhal
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA
| | - Vikram Khurana
- Department of Neurology, Building for Transformative Medicine Room 10016L, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, 02115, USA.
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4
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Mitsui J, Matsukawa T, Uemura Y, Kawahara T, Chikada A, Porto KJL, Naruse H, Tanaka M, Ishiura H, Toda T, Kuzuyama H, Hirano M, Wada I, Ga T, Moritoyo T, Takahashi Y, Mizusawa H, Ishikawa K, Yokota T, Kuwabara S, Sawamoto N, Takahashi R, Abe K, Ishihara T, Onodera O, Matsuse D, Yamasaki R, Kira JI, Katsuno M, Hanajima R, Ogata K, Takashima H, Matsushima M, Yabe I, Sasaki H, Tsuji S. High-dose ubiquinol supplementation in multiple-system atrophy: a multicentre, randomised, double-blinded, placebo-controlled phase 2 trial. EClinicalMedicine 2023; 59:101920. [PMID: 37256098 PMCID: PMC10225719 DOI: 10.1016/j.eclinm.2023.101920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 06/01/2023] Open
Abstract
Background Functionally impaired variants of COQ2, encoding an enzyme in biosynthesis of coenzyme Q10 (CoQ10), were found in familial multiple system atrophy (MSA) and V393A in COQ2 is associated with sporadic MSA. Furthermore, reduced levels of CoQ10 have been demonstrated in MSA patients. Methods This study was a multicentre, randomised, double-blinded, placebo-controlled phase 2 trial. Patients with MSA were randomly assigned (1:1) to either ubiquinol (1500 mg/day) or placebo. The primary efficacy outcome was the change in the unified multiple system atrophy rating scale (UMSARS) part 2 at 48 weeks. Efficacy was assessed in all patients who completed at least one efficacy assessment (full analysis set). Safety analyses included patients who completed at least one dose of investigational drug. This trial is registered with UMIN-CTR (UMIN000031771), where the drug name of MSA-01 was used to designate ubiquinol. Findings Between June 26, 2018, and May 27, 2019, 139 patients were enrolled and randomly assigned to the ubiquinol group (n = 69) or the placebo group (n = 70). A total of 131 patients were included in the full analysis set (63 in the ubiquinol group; 68 in the placebo group). This study met the primary efficacy outcome (least square mean difference in UMSARS part 2 score (-1.7 [95% CI, -3.2 to -0.2]; P = 0.023)). The ubiquinol group also showed better secondary efficacy outcomes (Barthel index, Scale for the Assessment and Rating of Ataxia, and time required to walk 10 m). Rates of adverse events potentially related to the investigational drug were comparable between ubiquinol (n = 15 [23.8%]) and placebo (n = 21 [30.9%]). Interpretation High-dose ubiquinol was well-tolerated and led to a significantly smaller decline of UMSARS part 2 score compared with placebo. Funding Japan Agency for Medical Research and Development.
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Affiliation(s)
- Jun Mitsui
- Department of Molecular Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Matsukawa
- Department of Molecular Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukari Uemura
- Department of Data Sciences, Biostatistics Section, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takuya Kawahara
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Ayaka Chikada
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kristine Joyce L. Porto
- Department of Molecular Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroya Naruse
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaki Tanaka
- Institute of Medical Genomics, International University of Health and Welfare, Narita, Japan
| | - Hiroyuki Ishiura
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruko Kuzuyama
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Mari Hirano
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Ikue Wada
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Toshio Ga
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Takashi Moritoyo
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuji Takahashi
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Hidehiro Mizusawa
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Kinya Ishikawa
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences and Center for Brain Integration Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takanori Yokota
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences and Center for Brain Integration Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Nobukatsu Sawamoto
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koji Abe
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomohiko Ishihara
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Dai Matsuse
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ritsuko Hanajima
- Division of Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Katsuhisa Ogata
- Department of Neurology, National Hospital Organization Higashisaitama National Hospital, Hasuda, Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Masaaki Matsushima
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ichiro Yabe
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hidenao Sasaki
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shoji Tsuji
- Department of Molecular Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Institute of Medical Genomics, International University of Health and Welfare, Narita, Japan
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5
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Duque KR, Vizcarra JA, Hill EJ, Espay AJ. Disease-modifying vs symptomatic treatments: Splitting over lumping. HANDBOOK OF CLINICAL NEUROLOGY 2023; 193:187-209. [PMID: 36803811 DOI: 10.1016/b978-0-323-85555-6.00020-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Clinical trials of putative disease-modifying therapies in neurodegeneration have obeyed the century-old principle of convergence, or lumping, whereby any feature of a clinicopathologic disease entity is considered relevant to most of those affected. While this convergent approach has resulted in important successes in trials of symptomatic therapies, largely aimed at correcting common neurotransmitter deficiencies (e.g., cholinergic deficiency in Alzheimer's disease or dopaminergic deficiency in Parkinson's disease), it has been consistently futile in trials of neuroprotective or disease-modifying interventions. As individuals affected by the same neurodegenerative disorder do not share the same biological drivers, splitting such disease into small molecular/biological subtypes, to match people to therapies most likely to benefit them, is vital in the pursuit of disease modification. We here discuss three paths toward the splitting needed for future successes in precision medicine: (1) encourage the development of aging cohorts agnostic to phenotype in order to enact a biology-to-phenotype direction of biomarker development and validate divergence biomarkers (present in some, absent in most); (2) demand bioassay-based recruitment of subjects into disease-modifying trials of putative neuroprotective interventions in order to match the right therapies to the right recipients; and (3) evaluate promising epidemiologic leads of presumed pathogenetic potential using Mendelian randomization studies before designing the corresponding clinical trials. The reconfiguration of disease-modifying efforts for patients with neurodegenerative disorders will require a paradigm shift from lumping to splitting and from proteinopathy to proteinopenia.
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Affiliation(s)
- Kevin R Duque
- James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, United States
| | - Joaquin A Vizcarra
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Emily J Hill
- James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, United States
| | - Alberto J Espay
- James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, United States.
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6
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Krismer F, Palma JA, Calandra-Buonaura G, Stankovic I, Vignatelli L, Berger AK, Falup-Pecurariu C, Foubert-Samier A, Höglinger G, Kaufmann H, Kellerman L, Kim HJ, Klockgether T, Levin J, Martinez-Martin P, Mestre TA, Pellecchia MT, Perlman S, Qureshi I, Rascol O, Schrag A, Seppi K, Shang H, Stebbins GT, Wenning GK, Singer W, Meissner WG. The Unified Multiple System Atrophy Rating Scale: Status, Critique, and Recommendations. Mov Disord 2022; 37:2336-2341. [PMID: 36074648 PMCID: PMC9771866 DOI: 10.1002/mds.29215] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 01/13/2023] Open
Abstract
The Unified Multiple System Atrophy (MSA) Rating Scale was developed to provide a surrogate marker of disease severity and clinical progression in patients with MSA. It is comprised of four subscales: UMSARS-I (12 items) rates patient-reported functional disability; UMSARS-II (14 items) assesses motor impairment based on a clinical examination; UMSARS-III records blood pressure and heart rate in the supine and standing positions; and UMSARS-IV (1 item) rates chore-based disability. Strengths of the UMSARS include its wide acceptance in the field, the comprehensive coverage of motor symptoms and its clinimetric properties (including reliability and validity). However, with its increasing use, potential areas of improvement in the UMSARS have become apparent. To address these limitations, a task force, involving clinicians, researchers, patient groups, and industry representatives, has recently been endorsed by the International Parkinson’s Disease and Movement Disorders Society. The present viewpoint summarizes strengths and weaknesses of the UMSARS and suggests a roadmap to develop an improved MSA clinical outcome assessment.
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Affiliation(s)
- Florian Krismer
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Jose-Alberto Palma
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Giovanna Calandra-Buonaura
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy,IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Iva Stankovic
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Serbia
| | - Luca Vignatelli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy,IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Anna-Karin Berger
- Clinical Science, Assessment and Innovation; Department of Clinical Development. Lundbeck, Valby, Denmark
| | - Cristian Falup-Pecurariu
- Department of Neurology, County Clinic Hospital, Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Alexandra Foubert-Samier
- CHU Bordeaux, Service de Neurologie des Maladies Neurodégénératives, IMNc, F-33000 Bordeaux, France
| | - Günter Höglinger
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany,Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Horacio Kaufmann
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Han-Joon Kim
- Department of Neurology and Movement Disorder Center, Seoul National University Hospital, Seoul, South Korea
| | - Thomas Klockgether
- Department of Neurology, University Hospital Bonn, Bonn, Germany,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Johannes Levin
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany,Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany,MODAG GmbH, Wendelsheim, Germany
| | - Pablo Martinez-Martin
- Center for Networked Biomedical Research in Neurodegenerative Diseases (CIBERNED), Carlos III Institute of Health. Madrid, Spain
| | - Tiago A. Mestre
- Parkinson’s Disease and Movement Disorders Center, Division of Neurology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa Brain and Mind Institute, Ottawa, Canada
| | - Maria Teresa Pellecchia
- Department of Medicine, Surgery and Dentistry, Neuroscience Section, University of Salerno, Salerno, Italy
| | - Susan Perlman
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Olivier Rascol
- French Reference Center for MSA, CIC 1436, NS-Park/FCRIN network and NeuroToul COEN Center, University Hospital of Toulouse, University of Toulouse 3 and INSERM, Toulouse, France
| | - Anette Schrag
- Department of Clinical Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Klaus Seppi
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Huifang Shang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, Rare Diseases Center, West China Hospital, Sichuan University, China
| | - Glenn T. Stebbins
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Gregor K. Wenning
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Wassilios G. Meissner
- CHU Bordeaux, Service de Neurologie des Maladies Neurodégénératives, IMNc, F-33000 Bordeaux, France,Univ. Bordeaux, CNRS, IMN, UMR 5293, F-33000 Bordeaux, France,Dept. Medicine, University of Otago, Christchurch, and New Zealand Brain Research Institute, Christchurch, New Zealand
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7
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Fabbri M, Foubert-Samier A, Pavy-le Traon A, Rascol O, Meissner WG. Atrofia multisistemica. Neurologia 2022. [DOI: 10.1016/s1634-7072(22)47094-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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8
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Vemuri P, Castillo AM, Thostenson KB, Ward CP, Raghavan S, Reid RI, Lesnick TG, Reddy AL, Gehrking TL, Gehrking JA, Sletten DM, Jack CR, Low PA, Singer W. Imaging biomarkers for early multiple system atrophy. Parkinsonism Relat Disord 2022; 103:60-68. [PMID: 36063706 PMCID: PMC10597684 DOI: 10.1016/j.parkreldis.2022.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To systematically evaluate structural MRI and diffusion MRI features for cross-sectional discrimination and tracking of longitudinal disease progression in early multiple system atrophy (MSA). METHODS In a prospective, longitudinal study of synucleinopathies with imaging on 14 controls and 29 MSA patients recruited at an early disease stage (15 predominant cerebellar ataxia subtype or MSA-C and 14 predominant parkinsonism subtype or MSA-P), we computed regional morphometric and diffusion MRI features. We identified morphometric features by ranking them based on their ability to distinguish MSA-C from controls and MSA-P from controls and evaluated diffusion changes in these regions. For the top performing regions, we evaluated their utility for tracking longitudinal disease progression using imaging from 12-month follow-up and computed sample size estimates for a hypothetical clinical trial in MSA. We also computed these selected morphometric features in an independent validation dataset. RESULTS We found that morphometric changes in the cerebellar white matter, brainstem, and pons can separate early MSA-C patients from controls both cross-sectionally and longitudinally (p < 0.01). The putamen and striatum, though useful for separating early MSA-P patients from control subjects at baseline, were not useful for tracking MSA disease progression. Cerebellum white matter diffusion changes aided in capturing early disease related degeneration in MSA. INTERPRETATION Regardless of clinically predominant features at the time of MSA assessment, brainstem and cerebellar pathways progressively deteriorate with disease progression. Quantitative measurements of these regions are promising biomarkers for MSA diagnosis in early disease stage and potential surrogate markers for future MSA clinical trials.
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Affiliation(s)
- Prashanthi Vemuri
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Anna M Castillo
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kaely B Thostenson
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Chadwick P Ward
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Robert I Reid
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Timothy G Lesnick
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ashritha L Reddy
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tonette L Gehrking
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jade A Gehrking
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - David M Sletten
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Clifford R Jack
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Phillip A Low
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA
| | - Wolfgang Singer
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN, 55905, USA.
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9
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Sidoroff V, Bower P, Stefanova N, Fanciulli A, Stankovic I, Poewe W, Seppi K, Wenning GK, Krismer F. Disease-Modifying Therapies for Multiple System Atrophy: Where Are We in 2022? JOURNAL OF PARKINSON'S DISEASE 2022; 12:1369-1387. [PMID: 35491799 PMCID: PMC9398078 DOI: 10.3233/jpd-223183] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Multiple system atrophy is a rapidly progressive and fatal neurodegenerative disorder. While numerous preclinical studies suggested efficacy of potentially disease modifying agents, none of those were proven to be effective in large-scale clinical trials. Three major strategies are currently pursued in preclinical and clinical studies attempting to slow down disease progression. These target α-synuclein, neuroinflammation, and restoration of neurotrophic support. This review provides a comprehensive overview on ongoing preclinical and clinical developments of disease modifying therapies. Furthermore, we will focus on potential shortcomings of previous studies that can be avoided to improve data quality in future studies of this rare disease.
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Affiliation(s)
- Victoria Sidoroff
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Pam Bower
- The Multiple System Atrophy Coalition, Inc., McLean, VA, USA
| | - Nadia Stefanova
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Iva Stankovic
- Neurology Clinic, University Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gregor K Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Krismer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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10
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Nwabufo CK, Aigbogun OP. Diagnostic and therapeutic agents that target alpha-synuclein in Parkinson's disease. J Neurol 2022; 269:5762-5786. [PMID: 35831620 PMCID: PMC9281355 DOI: 10.1007/s00415-022-11267-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 12/14/2022]
Abstract
The development of disease-modifying drugs and differential diagnostic agents is an urgent medical need in Parkinson’s disease. Despite the complex pathophysiological pathway, the misfolding of alpha-synuclein has been identified as a putative biomarker for detecting the onset and progression of the neurodegeneration associated with Parkinson’s disease. Identifying the most appropriate alpha-synuclein-based diagnostic modality with clinical translation will revolutionize the diagnosis of Parkinson’s. Likewise, molecules that target alpha-synuclein could alter the disease pathway that leads to Parkinson’s and may serve as first-in class therapeutics compared to existing treatment options such as levodopa and dopamine agonist that do not necessarily modify the disease pathway. Notwithstanding the promising benefits that alpha-synuclein presents to therapeutics and diagnostics development for Parkinson’s disease, finding ways to address potential challenges such as inadequate preclinical models, safety and efficacy will be paramount to achieving clinical translation. In this comprehensive review paper, we described the role of alpha-synuclein in the pathogenesis of Parkinson’s disease, as well as how its structure and function relationship delineate disease onset and progression. We further discussed different alpha-synuclein-based diagnostic modalities including biomolecular assays and molecular imaging. Finally, we presented current small molecules and biologics that are being developed as disease-modifying drugs or positron emission tomography imaging probes for Parkinson’s disease.
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Affiliation(s)
- Chukwunonso K Nwabufo
- Drug Discovery and Development Research Group, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada. .,Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, M5S 3M2, Canada.
| | - Omozojie P Aigbogun
- Drug Discovery and Development Research Group, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada.,Department of Chemistry, University of Saskatchewan, Saskatoon, Canada
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11
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Palma JA, Martinez J, Millar Vernetti P, Ma T, Perez MA, Zhong J, Qian Y, Dutta S, Maina KN, Siddique I, Bitan G, Ades-Aron B, Shepherd TM, Kang UJ, Kaufmann H. mTOR Inhibition with Sirolimus in Multiple System Atrophy: A Randomized, Double-Blind, Placebo-Controlled Futility Trial and 1-Year Biomarker Longitudinal Analysis. Mov Disord 2022; 37:778-789. [PMID: 35040506 PMCID: PMC9018525 DOI: 10.1002/mds.28923] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/01/2021] [Accepted: 12/27/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Multiple system atrophy (MSA) is a fatal neurodegenerative disease characterized by the aggregation of α-synuclein in glia and neurons. Sirolimus (rapamycin) is an mTOR inhibitor that promotes α-synuclein autophagy and reduces its associated neurotoxicity in preclinical models. OBJECTIVE To investigate the efficacy and safety of sirolimus in patients with MSA using a futility design. We also analyzed 1-year biomarker trajectories in the trial participants. METHODS Randomized, double-blind, parallel group, placebo-controlled clinical trial at the New York University of patients with probable MSA randomly assigned (3:1) to sirolimus (2-6 mg daily) for 48 weeks or placebo. Primary endpoint was change in the Unified MSA Rating Scale (UMSARS) total score from baseline to 48 weeks. (ClinicalTrials.gov NCT03589976). RESULTS The trial was stopped after a pre-planned interim analysis met futility criteria. Between August 15, 2018 and November 15, 2020, 54 participants were screened, and 47 enrolled and randomly assigned (35 sirolimus, 12 placebo). Of those randomized, 34 were included in the intention-to-treat analysis. There was no difference in change from baseline to week 48 between the sirolimus and placebo in UMSARS total score (mean difference, 2.66; 95% CI, -7.35-6.91; P = 0.648). There was no difference in UMSARS-1 and UMSARS-2 scores either. UMSARS scores changes were similar to those reported in natural history studies. Neuroimaging and blood biomarker results were similar in the sirolimus and placebo groups. Adverse events were more frequent with sirolimus. Analysis of 1-year biomarker trajectories in all participants showed that increases in blood neurofilament light chain (NfL) and reductions in whole brain volume correlated best with UMSARS progression. CONCLUSIONS Sirolimus for 48 weeks was futile to slow the progression of MSA and had no effect on biomarkers compared to placebo. One-year change in blood NfL and whole brain atrophy are promising biomarkers of disease progression for future clinical trials. © 2022 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Jose Martinez
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Thong Ma
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Miguel A. Perez
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Judy Zhong
- Department of Population Health, Division of Biostatistics, New York University Grossman School of Medicine, New York, NY, USA
| | - Yingzhi Qian
- Department of Population Health, Division of Biostatistics, New York University Grossman School of Medicine, New York, NY, USA
| | - Suman Dutta
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Katherine N. Maina
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Ibrar Siddique
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Gal Bitan
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA,Brain Research Institute, University of California, Los Angeles, CA, USA,Molecular Biology Institute, University of California, Los Angeles, CA, USA
| | - Benjamin Ades-Aron
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Timothy M. Shepherd
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Un Jung Kang
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
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12
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Wang ZX, Zhang NN, Zhao HX, Song J. Nocebo effect in multiple system atrophy: systematic review and meta-analysis of placebo-controlled clinical trials. Neurol Sci 2022; 43:899-905. [PMID: 34973075 PMCID: PMC8789733 DOI: 10.1007/s10072-021-05758-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 11/15/2021] [Indexed: 11/28/2022]
Abstract
Background Nocebo effect is prevalent among neurological diseases, resulting in low adherence and treatment outcome. We sought to examine the nocebo effect in randomized controlled trials (RCTs) in multiple system atrophy (MSA). Methods We searched RCTs in MSA from Medline since September, 2021. RCTs for drug treatment conducted in adult MSA patients with more than 5 cases in each treatment arm were included. We assessed the number of dropout due to placebo intolerance. We also did a symptomatic/disease-modifying subgroup analysis based on two different treatment purposes. The STATA software was used for statistical analysis. Overall heterogeneity was assessed using the Cochran Q and I2. Results Data were extracted from 11 RCTs fulfilling our search criteria. Of 540 placebo-treated patients, 64.2% reported at least one adverse event (AE) and 7.5% reported dropout because of AEs. The chance of dropping out because of an AE and experiencing at least one AE did not differ between placebo and active drug treatment arms. Besides, the pooled nocebo dropout rate in the symptomatic subgroup was similar to that of the disease-modifying subgroup. Conclusion In MSA RCTs, nocebo dropout rate was not at a low level among neurological disorders. Nocebo effect was an important reason of dropout because of AE in placebo and active drug treatment arms. Different treatment purposes may not influence nocebo effect.
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Affiliation(s)
- Zi-Xuan Wang
- Department of Geriatrics, the Affiliated Hospital of Qingdao University, Qingdao, 266071, China.
- Institute of Neuroregeneration and Neurorehabilition, Qingdao University, Qingdao, 266071, China.
| | - Nan-Nan Zhang
- Department of Geriatrics, the Affiliated Hospital of Qingdao University, Qingdao, 266071, China
| | - Hai-Xia Zhao
- Department of Neurology, the Third People's Hospital of Qingdao, Qingdao University, Qingdao, 266000, China
| | - Jie Song
- Department of Geriatrics, the Affiliated Hospital of Qingdao University, Qingdao, 266071, China
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13
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Chung SJ, Lee TY, Lee YH, Baik K, Jung JH, Yoo HS, Shim CJ, Eom H, Hong JY, Kim DJ, Sohn YH, Lee PH. Phase I Trial of Intra-arterial Administration of Autologous Bone Marrow-Derived Mesenchymal Stem Cells in Patients with Multiple System Atrophy. Stem Cells Int 2021; 2021:9886877. [PMID: 34712335 PMCID: PMC8548132 DOI: 10.1155/2021/9886877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND This study is aimed at investigating the safety and tolerability of the intra-arterial administration of autologous bone marrow-derived mesenchymal stem cells (BM-MSCs) in patients with multiple system atrophy- (MSA-) cerebellar type (MSA-C). METHODS This was a single-center, open-label phase I clinical trial in patients with MSA-C. A three-stage dose escalation scheme (low-dose, 3.0 × 105 cells/kg; medium-dose, 6.0 × 105 cells/kg; high-dose, 9.0 × 105 cells/kg) was applied to determine the maximum tolerated dose of intra-arterial administration of BM-MSCs based on the no-observed-adverse-effect level derived from the toxicity study. The occurrence of adverse events was evaluated 1 day before and 1, 14, and 28 days after BM-MSC therapy. Additionally, we assessed changes in the Unified MSA Rating Scale (UMSARS) score 3 months after BM-MSC treatment. RESULTS One serious adverse drug reaction (ADR) of leptomeningeal enhancement following the intra-arterial BM-MSC administration occurred in one patient in the low-dose group. The safety review of the Internal Monitoring Committee interpreted this as radiological evidence of the blood-brain barrier permeability for MSCs. No other ADRs were observed in the medium- or high-dose groups. In particular, no ischemic lesions on diffusion-weighted images were observed in any of the study participants. Additionally, the medium- and high-dose groups tended to show a slower increase in UMSARS scores than the low-dose group during the 3-month follow-up. CONCLUSION The present study confirmed that a single intra-arterial administration of autologous BM-MSCs is a safe and promising neuroprotective strategy in patients with MSA-C.
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Affiliation(s)
- Seok Jong Chung
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Department of Neurology, Yongin Severance Hospital, Yonsei University Health System, Yongin 16995, Republic of Korea
| | - Tae Yong Lee
- Bioengineering Institute, CORESTEM Inc., Seoul 04763, Republic of Korea
| | - Yang Hyun Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - KyoungWon Baik
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jin Ho Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan 47392, Republic of Korea
| | - Han Soo Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chang Jae Shim
- Bioengineering Institute, CORESTEM Inc., Seoul 04763, Republic of Korea
| | - Hyojin Eom
- Bioengineering Institute, CORESTEM Inc., Seoul 04763, Republic of Korea
| | - Ji-Yeon Hong
- Bioengineering Institute, CORESTEM Inc., Seoul 04763, Republic of Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Young H. Sohn
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Phil Hyu Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Current experimental disease-modifying therapeutics for multiple system atrophy. J Neural Transm (Vienna) 2021; 128:1529-1543. [PMID: 34398313 PMCID: PMC8528757 DOI: 10.1007/s00702-021-02406-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/08/2021] [Indexed: 02/06/2023]
Abstract
Multiple system atrophy (MSA) is a challenging neurodegenerative disorder with a difficult and often inaccurate early diagnosis, still lacking effective treatment. It is characterized by a highly variable clinical presentation with parkinsonism, cerebellar ataxia, autonomic dysfunction, and pyramidal signs, with a rapid progression and an aggressive clinical course. The definite MSA diagnosis is only possible post-mortem, when the presence of distinctive oligodendroglial cytoplasmic inclusions (GCIs), mainly composed of misfolded and aggregated α-Synuclein (α-Syn) is demonstrated. The process of α-Syn accumulation and aggregation within oligodendrocytes is accepted one of the main pathological events underlying MSA. However, MSA is considered a multifactorial disorder with multiple pathogenic events acting together including neuroinflammation, oxidative stress, and disrupted neurotrophic support, among others. The discussed here treatment approaches are based on our current understanding of the pathogenesis of MSA and the results of preclinical and clinical therapeutic studies conducted over the last 2 decades. We summarize leading disease-modifying approaches for MSA including targeting α-Syn pathology, modulation of neuroinflammation, and enhancement of neuroprotection. In conclusion, we outline some challenges related to the need to overcome the gap in translation between preclinical and clinical studies towards a successful disease modification in MSA.
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Nasal Rifampicin Improves Cognition in a Mouse Model of Dementia with Lewy Bodies by Reducing α-Synuclein Oligomers. Int J Mol Sci 2021; 22:ijms22168453. [PMID: 34445158 PMCID: PMC8395129 DOI: 10.3390/ijms22168453] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/29/2021] [Accepted: 08/04/2021] [Indexed: 12/02/2022] Open
Abstract
α-Synuclein oligomers are thought to play an important role in the pathogenesis of dementia with Lewy bodies (DLB). There is no effective cure for DLB at present. Previously, we demonstrated that in APP- and tau-transgenic mice, oral or intranasal rifampicin reduced brain Aβ and tau oligomers and improved mouse cognition. In the present study, we expanded our research to DLB. Rifampicin was intranasally administered to 6-month-old A53T-mutant α-synuclein-transgenic mice at 0.1 mg/day for 1 month. The mice displayed memory impairment but no motor deficit at this age, indicating a suitable model of DLB. α-Synuclein pathologies were examined by the immunohistochemical/biochemical analyses of brain tissues. Cognitive function was evaluated by the Morris water maze test. Intranasal rifampicin significantly reduced the levels of [pSer129] α-synuclein in the hippocampus and α-synuclein oligomers in the visual cortex and hippocampus. The level of the presynaptic marker synaptophysin in the hippocampus was recovered to the level in non-transgenic littermates. In the Morris water maze, a significant improvement in spatial reference memory was observed in rifampicin-treated mice. Taken together with our previous findings, these results suggest that intranasal rifampicin is a promising remedy for the prevention of neurodegenerative dementia, including Alzheimer’s disease, frontotemporal dementia, and DLB.
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Matsushima M, Yabe I, Sakushima K, Kanatani Y, Nishimoto N, Matsuoka T, Sawada J, Uesugi H, Sako K, Takei A, Tamakoshi A, Shimohama S, Sato N, Kikuchi S, Sasaki H. Multiple system atrophy in Hokkaido, Japan: a prospective registry study of natural history and symptom assessment scales followed for 5 years. BMJ Open 2021; 11:e045100. [PMID: 33558361 PMCID: PMC7871682 DOI: 10.1136/bmjopen-2020-045100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Multiple system atrophy (MSA) is a refractory neurodegenerative disease, but novel treatments are anticipated. An accurate natural history of MSA is important for clinical trials, but is insufficient. This regional registry was launched to complement clinical information on MSA. SETTING Patient recruitment started in November 2014 and is ongoing at the time of submission. The number of participating facilities was 66. Postal surveys were sent to medical facilities and patients with MSA in Hokkaido, Japan. PARTICIPANTS After obtaining written consent from 196 participants, 184 overview surveys and 115 detailed surveys were conducted. PRIMARY AND SECONDARY OUTCOME MEASURES An overview survey evaluated conformity to diagnostic criteria and a detailed survey implemented an annual assessment based on the Unified Multiple System Atrophy Rating Scale (UMSARS). RESULTS At the time of registration, 58.2% of patients were diagnosed with cerebellar symptoms predominant type MSA (MSA-C) and 29.9% were diagnosed with parkinsonism predominant type MSA (MSA-P). UMSARS Part Ⅳ score of 4 or 5 accounted for 53.8% of participants. The higher the UMSARS Part Ⅳ score, the higher the proportion of MSA-P. At baseline, levodopa was used by 69 patients (37.5%) and the average levodopa dose was 406.7 mg/day. The frequency of levodopa use increased over time. Eleven cases changed from MSA-C to MSA-P during the study, but the opposite was not observed. Information about survival and causes of death was collected on 54 cases. Half of deaths were respiratory-related. Sudden death was recorded even in the group with UMSARS Part Ⅳ score of 1. CONCLUSIONS This study is the first large-scale prospective MSA cohort study in Asia. MSA-C was dominant, but the use of antiparkinsonian drugs increased over the study period. Changes from MSA-C to MSA-P occurred, but not vice versa.
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Affiliation(s)
- Masaaki Matsushima
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Ichiro Yabe
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Ken Sakushima
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Yasuhiro Kanatani
- Department of Health Crisis Management, National Institute of Public Health, Wako, Saitama, Japan
- Department of Clinical Pharmacology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Naoki Nishimoto
- Department of Biostatistics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Takeshi Matsuoka
- Department of Neurology, Date Red Cross Hospital, Date, Hokkaido, Japan
| | - Jun Sawada
- Cardiovascular, Respiratory and Neurology Division, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Haruo Uesugi
- Department of Medical Service, Aizen Hospital, Sapporo, Hokkaido, Japan
- Department of Neurology, Oji General Hospital, Tomakomai, Hokkaido, Japan
| | - Kazuya Sako
- Department of Neurology, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Asako Takei
- Hokuyukai Neurological Hospital, Sapporo, Hokkaido, Japan
| | - Akiko Tamakoshi
- Department of Public Health, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Shun Shimohama
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Norihiro Sato
- Hokkaido University Hospital Clinical Research and Medical Innovation Center, Sapporo, Hokkaido, Japan
| | | | - Hidenao Sasaki
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
- Hakodate Central General Hospital, Hakodate, Hokkaido, Japan
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Palma JA, Vernetti PM, Perez MA, Krismer F, Seppi K, Fanciulli A, Singer W, Low P, Biaggioni I, Norcliffe-Kaufmann L, Pellecchia MT, Martí MJ, Kim HJ, Merello M, Stankovic I, Poewe W, Betensky R, Wenning G, Kaufmann H. Limitations of the Unified Multiple System Atrophy Rating Scale as outcome measure for clinical trials and a roadmap for improvement. Clin Auton Res 2021; 31:157-164. [PMID: 33554315 PMCID: PMC7868077 DOI: 10.1007/s10286-021-00782-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/27/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE The unified multiple system atrophy (MSA) rating scale (UMSARS) was developed almost 20 years ago as a clinical rating scale to capture multiple aspects of the disease. With its widespread use, the shortcomings of the UMSARS as a clinical outcome assessment (COA) have become increasingly apparent. We here summarize the shortcomings of the scale, confirm some of its limitations with data from the Natural History Study of the Synucleinopathies (NHSS), and suggest a framework to develop and validate an improved COA to be used in future clinical trials of disease-modifying drugs in patients with MSA. METHODS Expert consensus assessment of the limitations of the UMSARS and recommendations for the development and validation of a novel COA for MSA. We used UMSARS data from the ongoing NHSS (ClinicalTrials.gov: NCT01799915) to showcase some of these limitations. RESULTS The UMSARS in general, and specific items in particular, have limitations to detect change resulting in a ceiling effect. Some items have specific limitations including unclear anchoring descriptions, lack of correlation with disease severity, susceptibility to improve with symptomatic therapies (e.g., orthostatic hypotension, constipation, and bladder dysfunction), and redundancy, among others. CONCLUSIONS Because of the limitations of the UMSARS, developing and validating an improved COA is a priority. The time is right for academic MSA clinicians together with industry, professional societies, and patient advocacy groups to develop and validate a new COA.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Av, Suite 9Q, New York, NY, 10016, USA
| | - Patricio Millar Vernetti
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Av, Suite 9Q, New York, NY, 10016, USA
| | - Miguel A Perez
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Av, Suite 9Q, New York, NY, 10016, USA
| | - Florian Krismer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Wolfgang Singer
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Phillip Low
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Italo Biaggioni
- Department of Medicine and Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Av, Suite 9Q, New York, NY, 10016, USA
| | | | - Maria José Martí
- Movement Disorders Unit, Department of Neurology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Han-Joon Kim
- Department of Neurology, Seoul Medical University, Seoul, South Korea
| | | | - Iva Stankovic
- Neurology Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rebecca Betensky
- New York University School of Global Public Health, New York, NY, USA
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Av, Suite 9Q, New York, NY, 10016, USA.
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Terry C. Insights from nature: A review of natural compounds that target protein misfolding in vivo. CURRENT RESEARCH IN BIOTECHNOLOGY 2020. [DOI: 10.1016/j.crbiot.2020.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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19
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Fouka M, Mavroeidi P, Tsaka G, Xilouri M. In Search of Effective Treatments Targeting α-Synuclein Toxicity in Synucleinopathies: Pros and Cons. Front Cell Dev Biol 2020; 8:559791. [PMID: 33015057 PMCID: PMC7500083 DOI: 10.3389/fcell.2020.559791] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022] Open
Abstract
Parkinson's disease (PD), multiple system atrophy (MSA) and Dementia with Lewy bodies (DLB) represent pathologically similar, progressive neurodegenerative disorders characterized by the pathological aggregation of the neuronal protein α-synuclein. PD and DLB are characterized by the abnormal accumulation and aggregation of α-synuclein in proteinaceous inclusions within neurons named Lewy bodies (LBs) and Lewy neurites (LNs), whereas in MSA α-synuclein inclusions are mainly detected within oligodendrocytes named glial cytoplasmic inclusions (GCIs). The presence of pathologically aggregated α-synuclein along with components of the protein degradation machinery, such as ubiquitin and p62, in LBs and GCIs is considered to underlie the pathogenic cascade that eventually leads to the severe neurodegeneration and neuroinflammation that characterizes these diseases. Importantly, α-synuclein is proposed to undergo pathogenic misfolding and oligomerization into higher-order structures, revealing self-templating conformations, and to exert the ability of "prion-like" spreading between cells. Therefore, the manner in which the protein is produced, is modified within neural cells and is degraded, represents a major focus of current research efforts in the field. Given that α-synuclein protein load is critical to disease pathogenesis, the identification of means to limit intracellular protein burden and halt α-synuclein propagation represents an obvious therapeutic approach in synucleinopathies. However, up to date the development of effective therapeutic strategies to prevent degeneration in synucleinopathies is limited, due to the lack of knowledge regarding the precise mechanisms underlying the observed pathology. This review critically summarizes the recent developed strategies to counteract α-synuclein toxicity, including those aimed to increase protein degradation, to prevent protein aggregation and cell-to-cell propagation, or to engage antibodies against α-synuclein and discuss open questions and unknowns for future therapeutic approaches.
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Affiliation(s)
| | | | | | - Maria Xilouri
- Center of Clinical Research, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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20
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Singer W, Schmeichel AM, Shahnawaz M, Schmelzer JD, Boeve BF, Sletten DM, Gehrking TL, Gehrking JA, Olson AD, Savica R, Suarez MD, Soto C, Low PA. Alpha-Synuclein Oligomers and Neurofilament Light Chain in Spinal Fluid Differentiate Multiple System Atrophy from Lewy Body Synucleinopathies. Ann Neurol 2020; 88:503-512. [PMID: 32557811 PMCID: PMC7719613 DOI: 10.1002/ana.25824] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/02/2020] [Accepted: 06/14/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To explore the role of alpha-synuclein (αSyn) oligomers and neurofilament light chain (NFL) in cerebrospinal fluid (CSF) as markers of early multiple system atrophy (MSA) and to contrast findings with Lewy body synucleinopathies. METHODS In a discovery cohort of well-characterized early MSA patients (n = 24) and matched healthy controls (CON, n = 14), we utilized enzyme-linked immunosorbent assay to measure NFL and protein misfolding cyclic amplification (PMCA) to detect αSyn oligomers in CSF. We confirmed findings in a separate prospectively enrolled cohort of patients with early MSA (n = 38), Parkinson disease (PD, n = 16), and dementia with Lewy bodies (DLB, n = 13), and CON subjects (n = 15). RESULTS In the discovery cohort, NFL was markedly elevated in MSA patients, with perfect separation from CON. αSyn-PMCA was nonreactive in all CON, whereas all MSA samples were positive. In the confirmatory cohort, NFL again perfectly separated MSA from CON, and was significantly lower in PD and DLB compared to MSA. PMCA was again nonreactive in all CON, and positive in all but 2 MSA cases. All PD and all but 2 DLB samples were also positive for αSyn aggregates but with markedly different reaction kinetics from MSA; aggregation occurred later, but maximum fluorescence was higher, allowing for perfect separation of reactive samples between MSA and Lewy body synucleinopathies. INTERPRETATION NFL and αSyn oligomers in CSF faithfully differentiate early MSA not only from CON but also from Lewy body synucleinopathies. The findings support the role of these markers as diagnostic biomarkers, and have important implications for understanding pathophysiologic mechanisms underlying the synucleinopathies. ANN NEUROL 2020;88:503-512.
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Affiliation(s)
- Wolfgang Singer
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mohammad Shahnawaz
- Mitchell Center for Alzheimer's Disease and Related Brain Disorders, Department of Neurology, University of Texas McGovern Medical School at Houston, Houston, Texas, USA
| | | | - Bradley F Boeve
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Sletten
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jade A Gehrking
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anita D Olson
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rodolfo Savica
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Claudio Soto
- Mitchell Center for Alzheimer's Disease and Related Brain Disorders, Department of Neurology, University of Texas McGovern Medical School at Houston, Houston, Texas, USA
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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21
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Anti-aggregation Effects of Phenolic Compounds on α-synuclein. Molecules 2020; 25:molecules25102444. [PMID: 32456274 PMCID: PMC7288075 DOI: 10.3390/molecules25102444] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022] Open
Abstract
The aggregation and deposition of α-synuclein (αS) are major pathologic features of Parkinson’s disease, dementia with Lewy bodies, and other α-synucleinopathies. The propagation of αS pathology in the brain plays a key role in the onset and progression of clinical phenotypes. Thus, there is increasing interest in developing strategies that attenuate αS aggregation and propagation. Based on cumulative evidence that αS oligomers are neurotoxic and critical species in the pathogenesis of α-synucleinopathies, we and other groups reported that phenolic compounds inhibit αS aggregation including oligomerization, thereby ameliorating αS oligomer-induced cellular and synaptic toxicities. Heterogeneity in gut microbiota may influence the efficacy of dietary polyphenol metabolism. Our recent studies on the brain-penetrating polyphenolic acids 3-hydroxybenzoic acid (3-HBA), 3,4-dihydroxybenzoic acid (3,4-diHBA), and 3-hydroxyphenylacetic acid (3-HPPA), which are derived from gut microbiota-based metabolism of dietary polyphenols, demonstrated an in vitro ability to inhibit αS oligomerization and mediate aggregated αS-induced neurotoxicity. Additionally, 3-HPPA, 3,4-diHBA, 3-HBA, and 4-hydroxybenzoic acid significantly attenuated intracellular αS seeding aggregation in a cell-based system. This review focuses on recent research developments regarding neuroprotective properties, especially anti-αS aggregation effects, of phenolic compounds and their metabolites by the gut microbiome, including our findings in the pathogenesis of α-synucleinopathies.
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22
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Heras-Garvin A, Stefanova N. MSA: From basic mechanisms to experimental therapeutics. Parkinsonism Relat Disord 2020; 73:94-104. [PMID: 32005598 DOI: 10.1016/j.parkreldis.2020.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 01/16/2023]
Abstract
Multiple system atrophy (MSA) is a rare and fatal neurodegenerative disorder characterized by rapidly progressive autonomic and motor dysfunction. Pathologically, MSA is mainly characterized by the abnormal accumulation of misfolded α-synuclein in the cytoplasm of oligodendrocytes, which plays a major role in the pathogenesis of the disease. Striatonigral degeneration and olivopontecerebellar atrophy underlie the motor syndrome, while degeneration of autonomic centers defines the autonomic failure in MSA. At present, there is no treatment that can halt or reverse its progression. However, over the last decade several studies in preclinical models and patients have helped to better understand the pathophysiological events underlying MSA. The etiology of this fatal disorder remains unclear and may be multifactorial, caused by a combination of factors which may serve as targets for novel therapeutic approaches. In this review, we summarize the current knowledge about the etiopathogenesis and neuropathology of MSA, its different preclinical models, and the main disease modifying therapies that have been used so far or that are planned for future clinical trials.
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Affiliation(s)
- Antonio Heras-Garvin
- Division of Neurobiology, Department of Neurology, Medical University of Innsbruck, Austria.
| | - Nadia Stefanova
- Division of Neurobiology, Department of Neurology, Medical University of Innsbruck, Austria.
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23
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Fanciulli A, Stankovic I, Krismer F, Seppi K, Levin J, Wenning GK. Multiple system atrophy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2019; 149:137-192. [PMID: 31779811 DOI: 10.1016/bs.irn.2019.10.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Multiple system atrophy (MSA) is a sporadic, adult-onset, relentlessly progressive neurodegenerative disorder, clinically characterized by various combinations of autonomic failure, parkinsonism and ataxia. The neuropathological hallmark of MSA are glial cytoplasmic inclusions consisting of misfolded α-synuclein. Selective atrophy and neuronal loss in striatonigral and olivopontocerebellar systems underlie the division into two main motor phenotypes of MSA-parkinsonian type and MSA-cerebellar type. Isolated autonomic failure and REM sleep behavior disorder are common premotor features of MSA. Beyond the core clinical symptoms, MSA manifests with a number of non-motor and motor features. Red flags highly specific for MSA may provide clues for a correct diagnosis, but in general the diagnostic accuracy of the second consensus criteria is suboptimal, particularly in early disease stages. In this chapter, the authors discuss the historical milestones, etiopathogenesis, neuropathological findings, clinical features, red flags, differential diagnosis, diagnostic criteria, imaging and other biomarkers, current treatment, unmet needs and future treatments for MSA.
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Affiliation(s)
| | - Iva Stankovic
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Florian Krismer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Levin
- Department of Neurology, Ludwig-Maximilians-Universität München, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) e.V., Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Gregor K Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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24
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Meissner WG, Fernagut PO, Dehay B, Péran P, Traon APL, Foubert-Samier A, Lopez Cuina M, Bezard E, Tison F, Rascol O. Multiple System Atrophy: Recent Developments and Future Perspectives. Mov Disord 2019; 34:1629-1642. [PMID: 31692132 DOI: 10.1002/mds.27894] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/03/2019] [Accepted: 09/15/2019] [Indexed: 02/06/2023] Open
Abstract
Multiple system atrophy (MSA) is a rare and fatal neurodegenerative disorder characterized by a variable combination of parkinsonism, cerebellar impairment, and autonomic dysfunction. The pathologic hallmark is the accumulation of aggregated α-synuclein in oligodendrocytes, forming glial cytoplasmic inclusions, which qualifies MSA as a synucleinopathy together with Parkinson's disease and dementia with Lewy bodies. The underlying pathogenesis is still not well understood. Some symptomatic treatments are available, whereas neuroprotection remains an urgent unmet treatment need. In this review, we critically appraise significant developments of the past decade with emphasis on pathogenesis, diagnosis, prognosis, and treatment development. We further discuss unsolved questions and highlight some perspectives. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Wassilios G Meissner
- CRMR Atrophie Multisystématisée, CHU Bordeaux, Service de Neurologie, Bordeaux, France.,Institut des Maladies Neurodégénératives, Univ. de Bordeaux, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, Bordeaux, France.,Dept. of Medicine, University of Otago, Christchurch, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Pierre-Olivier Fernagut
- Institut des Maladies Neurodégénératives, Univ. de Bordeaux, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, Bordeaux, France.,Laboratoire de Neurosciences Expérimentales et Cliniques, Université de Poitiers, Poitiers, France.,INSERM, Laboratoire de Neurosciences Expérimentales et Cliniques, Poitiers, France
| | - Benjamin Dehay
- Institut des Maladies Neurodégénératives, Univ. de Bordeaux, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, Bordeaux, France
| | - Patrice Péran
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Toulouse, France
| | - Anne Pavy-Le Traon
- Services de Neurologie, CRMR Atrophie Multisystématisée, Toulouse, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France
| | - Alexandra Foubert-Samier
- CRMR Atrophie Multisystématisée, CHU Bordeaux, Service de Neurologie, Bordeaux, France.,Institut des Maladies Neurodégénératives, Univ. de Bordeaux, Bordeaux, France.,Inserm, Bordeaux Population Health Research Center, Bordeaux University, Bordeaux, France
| | - Miguel Lopez Cuina
- Institut des Maladies Neurodégénératives, Univ. de Bordeaux, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, Bordeaux, France
| | - Erwan Bezard
- Institut des Maladies Neurodégénératives, Univ. de Bordeaux, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, Bordeaux, France
| | - François Tison
- CRMR Atrophie Multisystématisée, CHU Bordeaux, Service de Neurologie, Bordeaux, France.,Institut des Maladies Neurodégénératives, Univ. de Bordeaux, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, Bordeaux, France
| | - Olivier Rascol
- Services de Neurologie et de Pharmacologie Clinique, Centre de Reference AMS, Centre d'Investigation Clinique, Réseau NS-Park/FCRIN et Centre of Excellence for Neurodegenerative Disorders (COEN) de Toulouse, CHU de Toulouse, Toulouse 3 University, Toulouse, France
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25
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Xiang C, Han S, Nao J, Cong S. MicroRNAs Dysregulation and Metabolism in Multiple System Atrophy. Front Neurosci 2019; 13:1103. [PMID: 31680837 PMCID: PMC6811505 DOI: 10.3389/fnins.2019.01103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022] Open
Abstract
Multiple system atrophy (MSA) is an adult onset, fatal disease, characterized by an accumulation of alpha-synuclein (α-syn) in oligodendroglial cells. MicroRNAs (miRNAs) are small non-coding RNAs involved in post-translational regulation and several biological processes. Disruption of miRNA-related pathways in the central nervous system (CNS) plays an important role in the pathogenesis of neurodegenerative diseases, including MSA. While the exact mechanisms underlying miRNAs in the pathogenesis of MSA remain unclear, it is known that miRNAs can repress the translation of messenger RNAs (mRNAs) that regulate the following pathogenesis associated with MSA: autophagy, neuroinflammation, α-syn accumulation, synaptic transmission, oxidative stress, and apoptosis. In this review, the metabolism of miRNAs and their functional roles in the pathogenesis of MSA are discussed, thereby highlighting miRNAs as potential new biomarkers for the diagnosis of MSA and in increasing our understanding of the disease process.
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Affiliation(s)
- Chunchen Xiang
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shunchang Han
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jianfei Nao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shuyan Cong
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
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26
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Ozansoy M, Coşkun E, Çetin Ozansoy MB, Çankaya Ş, Günal MY, Bayraktaroğlu Z, Yuluğ B, Hanoğlu L. Lazer aksotomi sonrası primer kortikal nöron kültüründe rifampisinin nöronal hücre sağkalımı üzerine etkisi. ACTA MEDICA ALANYA 2019. [DOI: 10.30565/medalanya.553846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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27
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Heim B, Krismer F, Poewe W, Seppi K. Imaging markers of disease progression in multiple system atrophy. FUTURE NEUROLOGY 2019. [DOI: 10.2217/fnl-2018-0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Different neuroimaging modalities hold potential as surrogate markers of underlying neurodegeneration in multiple system atrophy (MSA) and may reflect cell loss, altered glucose metabolism, microglial proliferation, astroglial activation, and nigrostriatal denervation. Multiple studies have demonstrated that serial structural and functional imaging studies are capable of demonstrating neurodegeneration in MSA patients quantitatively, which allows sample size estimates based on rates of progression of these neuroimaging markers. This review summarizes recent research findings as a tool to assess longitudinal changes of serial neuroimaging-derived parameters in MSA.
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Affiliation(s)
- Beatrice Heim
- Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Florian Krismer
- Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria
- Neuroimaging Research Core Facility, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria
- Neuroimaging Research Core Facility, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria
- Neuroimaging Research Core Facility, Medical University Innsbruck, 6020 Innsbruck, Austria
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Levin J, Maaß S, Schuberth M, Giese A, Oertel WH, Poewe W, Trenkwalder C, Wenning GK, Mansmann U, Südmeyer M, Eggert K, Mollenhauer B, Lipp A, Löhle M, Classen J, Münchau A, Kassubek J, Gandor F, Berg D, Egert-Schwender S, Eberhardt C, Paul F, Bötzel K, Ertl-Wagner B, Huppertz HJ, Ricard I, Höglinger GU. Safety and efficacy of epigallocatechin gallate in multiple system atrophy (PROMESA): a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2019; 18:724-735. [PMID: 31278067 DOI: 10.1016/s1474-4422(19)30141-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 03/24/2019] [Accepted: 03/27/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Multiple system atrophy is a rare neurodegenerative disease characterised by aggregation of α-synuclein in oligodendrocytes and neurons. The polyphenol epigallocatechin gallate inhibits α-synuclein aggregation and reduces associated toxicity. We aimed to establish if epigallocatechin gallate could safely slow disease progression in patients with multiple system atrophy. METHODS We did a randomised, double-blind, parallel group, placebo-controlled clinical trial at 12 specialist centres in Germany. Eligible participants were older than 30 years; met consensus criteria for possible or probable multiple system atrophy and could ambulate independently (ie, were at Hoehn and Yahr stages 1-3); and were on stable anti-Parkinson's, anti-dysautonomia, anti-dementia, and anti-depressant regimens (if necessary) for at least 1 month. Participants were randomly assigned (1:1) to epigallocatechin gallate or placebo (mannitol) via a web-generated permuted blockwise randomisation list (block size=2) that was stratified by disease subtype (parkinsonism-predominant disease vs cerebellar-ataxia-predominant disease). All participants and study personnel were masked to treatment assignment. Participants were given one hard gelatin capsule (containing either 400 mg epigallocatechin gallate or mannitol) orally once daily for 4 weeks, then one capsule twice daily for 4 weeks, and then one capsule three times daily for 40 weeks. After 48 weeks, all patients underwent a 4-week wash-out period. The primary endpoint was change in motor examination score of the Unified Multiple System Atrophy Rating Scale (UMSARS) from baseline to 52 weeks. Efficacy analyses were done in all people who received at least one dose of study medication. Safety was analysed in all people who received at least one dose of the study medication to which they had been randomly assigned. This trial is registered with ClinicalTrials.gov (NCT02008721) and EudraCT (2012-000928-18), and is completed. FINDINGS Between April 23, 2014, and Sept 3, 2015, 127 participants were screened and 92 were randomly assigned-47 to epigallocatechin gallate and 45 to placebo. Of these, 67 completed treatment and 64 completed the study (altough one of these patients had a major protocol violation). There was no evidence of a difference in the mean change from baseline to week 52 in motor examination scores on UMSARS between the epigallocatechin gallate (5·66 [SE 1·01]) and placebo (6·60 [0·99]) groups (mean difference -0·94 [SE 1·41; 95% CI -3·71 to 1·83]; p=0·51). Four patients in the epigallocatechin gallate group and two in the placebo group died. Two patients in the epigallocatechin gallate group had to stop treatment because of hepatotoxicity. INTERPRETATION 48 weeks of epigallocatechin gallate treatment did not modify disease progression in patients with multiple system atrophy. Epigallocatechin gallate was overall well tolerated but was associated with hepatotoxic effects in some patients, and thus doses of more than 1200 mg should not be used. FUNDING ParkinsonFonds Deutschland, German Parkinson Society, German Neurology Foundation, Lüneburg Foundation, Bischof Dr Karl Golser Foundation, and Dr Arthur Arnstein Foundation.
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Affiliation(s)
- Johannes Levin
- Department of Neurology, Ludwig-Maximilians-University Munich, Munich, Germany; German Center for Neurodegenerative Diseases, Munich, Germany; Munich Cluster for Systems Neurology, Munich, Germany
| | - Sylvia Maaß
- German Center for Neurodegenerative Diseases, Munich, Germany; Munich Cluster for Systems Neurology, Munich, Germany; Department of Neurology, Technical University Munich, Munich, Germany
| | - Madeleine Schuberth
- Department of Neurology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Armin Giese
- Center for Neuropathology and Prion Research, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Wolfgang H Oertel
- Department of Neurology, Philipps-Universität Marburg, Marburg, Germany
| | - Werner Poewe
- Department of Neurobiology, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Claudia Trenkwalder
- Paracelsus-Elena-Klinik, Kassel, Germany; Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Gregor K Wenning
- Department of Neurobiology, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Ulrich Mansmann
- Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martin Südmeyer
- Institute of Clinical Neuroscience and Medical Psychology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Karla Eggert
- Department of Neurology, Philipps-Universität Marburg, Marburg, Germany
| | - Brit Mollenhauer
- Paracelsus-Elena-Klinik, Kassel, Germany; Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Axel Lipp
- Department of Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Matthias Löhle
- Department of Neurology, University of Rostock, Rostock, Germany; German Center for Neurodegenerative Diseases, Rostock, Germany; Department of Neurology, Technische Universität Dresden, Dresden, Germany
| | - Joseph Classen
- Department of Neurology, University of Leipzig, Leipzig Germany
| | | | - Jan Kassubek
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Florin Gandor
- Movement Disorders Hospital, Beelitz-Heilstätten, Germany
| | - Daniela Berg
- Department of Neurodegeneration, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; Department of Neurology, Christian-Albrechts-University Kiel, Kiel, Germany
| | | | - Cornelia Eberhardt
- Pharmacy Department, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friedemann Paul
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Max Delbrueck Center for Molecular Medicine, NeuroCure Experimental and Clinical Research Center, Berlin, Germany
| | - Kai Bötzel
- Department of Neurology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Birgit Ertl-Wagner
- Department of Radiology, Ludwig-Maximilians-University Munich, Munich, Germany; Department of Radiology, The Hopsital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Ingrid Ricard
- Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Günter U Höglinger
- German Center for Neurodegenerative Diseases, Munich, Germany; Department of Neurology, Technical University Munich, Munich, Germany; Department of Neurology, Hanover Medical School, Hanover, Germany.
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Singer W, Dietz AB, Zeller AD, Gehrking TL, Schmelzer JD, Schmeichel AM, Gehrking JA, Suarez MD, Sletten DM, Minota Pacheco KV, Coon EA, Sandroni P, Benarroch EE, Fealey RD, Matsumoto JY, Bower JH, Hassan A, McKeon A, Windebank AJ, Mandrekar JN, Low PA. Intrathecal administration of autologous mesenchymal stem cells in multiple system atrophy. Neurology 2019; 93:e77-e87. [PMID: 31152011 PMCID: PMC6659003 DOI: 10.1212/wnl.0000000000007720] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 02/14/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE This phase I/II study sought to explore intrathecal administration of mesenchymal stem cells (MSCs) as therapeutic approach to multiple system atrophy (MSA). METHODS Utilizing a dose-escalation design, we delivered between 10 and 200 million adipose-derived autologous MSCs intrathecally to patients with early MSA. Patients were closely followed with clinical, laboratory, and imaging surveillance. Primary endpoints were frequency and type of adverse events; key secondary endpoint was the rate of disease progression assessed by the Unified MSA Rating Scale (UMSARS). RESULTS Twenty-four patients received treatment. There were no attributable serious adverse events, and injections were generally well-tolerated. At the highest dose tier, 3 of 4 patients developed low back/posterior leg pain, associated with thickening/enhancement of lumbar nerve roots. Although there were no associated neurologic deficits, we decided that dose-limiting toxicity was reached. A total of 6 of 12 patients in the medium dose tier developed similar, but milder and transient discomfort. Rate of progression (UMSARS total) was markedly lower compared to a matched historical control group (0.40 ± 0.59 vs 1.44 ± 1.42 points/month, p = 0.004) with an apparent dose-dependent effect. CONCLUSIONS Intrathecal MSC administration in MSA is safe and well-tolerated but can be associated with a painful implantation response at high doses. Compelling dose-dependent efficacy signals are the basis for a planned placebo-controlled trial. CLASSIFICATION OF EVIDENCE This phase I/II study provides Class IV evidence that for patients with early MSA, intrathecal MSC administration is safe, may result in a painful implantation response at high doses, and is associated with dose-dependent efficacy signals.
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Affiliation(s)
- Wolfgang Singer
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN.
| | - Allan B Dietz
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Anita D Zeller
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Tonette L Gehrking
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - James D Schmelzer
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Ann M Schmeichel
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Jade A Gehrking
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Mariana D Suarez
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - David M Sletten
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Karla V Minota Pacheco
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Elizabeth A Coon
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Paola Sandroni
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Eduardo E Benarroch
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Robert D Fealey
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Joseph Y Matsumoto
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - James H Bower
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Anhar Hassan
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Andrew McKeon
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Anthony J Windebank
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Jay N Mandrekar
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
| | - Phillip A Low
- From the Departments of Neurology (W.S., A.D.Z., T.L.G., J.D.S., A.M.S., J.A.G., M.D.S., D.M.S., K.V.M.P., E.A.C., P.S., E.E.B., R.D.F., J.Y.M., J.H.B., A.H., A.M., A.J.W., P.A.L.), Laboratory Medicine and Pathology (A.B.D.), and Biomedical Statistics and Informatics (J.N.M.), Mayo Clinic, Rochester, MN
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Moretti DV. Available and future treatments for atypical parkinsonism. A systematic review. CNS Neurosci Ther 2019; 25:159-174. [PMID: 30294976 PMCID: PMC6488913 DOI: 10.1111/cns.13068] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/01/2018] [Accepted: 09/05/2018] [Indexed: 01/02/2023] Open
Abstract
AIMS Success in treating patients with atypical parkinsonian syndromes, namely progressive supranuclear palsy (PSP), cortico-basal degeneration (CBD), multiple system atrophy (MSA), Parkinson's disease with dementia (PDD), and Lewy body dementia with (LBD), remains exceedingly low. The present work overviews the most influential research literature collected on MEDLINE, ISI Web of Science, Cochrane Library, and Scopus for available treatment in atypical parkinsonisms without time restriction. DISCUSSION Transdermal rotigotine, autologous mesenchymal stem cells, tideglusib, and coenzyme Q10 along with donepezil, rivastigmine, memantine, and the deep brain stimulation have shown some benefits in alleviating symptoms in APS. Moreover, many new clinical trials are ongoing testing microtubule stabilizer, antitau monoclonal antibody, tau acetylation inhibition, cell replacement, selective serotonin reuptake inhibitor, active immunization, inhibition of toxic α-synuclein oligomers formation, and inhibition of microglia. CONCLUSION A detailed knowledge of the pathological mechanism underlying the disorders is needed, and disease-modifying therapies are required to offer better therapeutic options to physician and caregivers of APS patients.
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Olfati N, Shoeibi A, Litvan I. Progress in the treatment of Parkinson-Plus syndromes. Parkinsonism Relat Disord 2019; 59:101-110. [DOI: 10.1016/j.parkreldis.2018.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 01/04/2023]
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Oliveri V. Toward the discovery and development of effective modulators of α-synuclein amyloid aggregation. Eur J Med Chem 2019; 167:10-36. [PMID: 30743095 DOI: 10.1016/j.ejmech.2019.01.045] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 12/17/2022]
Abstract
A host of human diseases, including Parkinson's disease and Dementia with Lewy bodies, are suspected to be directly linked to protein aggregation. Amyloid protein aggregates and oligomeric intermediates of α-synuclein are observed in synucleinopathies and considered to be mediators of cellular toxicity. Hence, α-synuclein has seen as one of the leading and most compelling targets and is receiving a great deal of attention from researchers. Nevertheless, there is no neuroprotective approach directed toward Parkinson's disease or other synucleinopathies so far. In this review, we summarize the available data concerning inhibitors of α-synuclein aggregation and their advancing towards clinical use. The compounds are grouped according to their chemical structures, providing respective insights into their mechanism of action, pharmacology, and pharmacokinetics. Overall, shared structure-activity elements are emerging, as well as specific binding modes related to the ability of the modulators to establish hydrophobic and hydrogen bonds interactions with the protein. Some molecules with encouraging in vivo data support the possibility of translation to the clinic.
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Affiliation(s)
- Valentina Oliveri
- Dipartimento di Scienze Chimiche, Università degli Studi di Catania, viale A. Doria 6, 95125, Catania, Italy.
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Abnormalities on structural MRI associate with faster disease progression in multiple system atrophy. Parkinsonism Relat Disord 2019; 58:23-27. [DOI: 10.1016/j.parkreldis.2018.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/22/2018] [Accepted: 08/06/2018] [Indexed: 11/22/2022]
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Ferreira JJ, Trenkwalder C, Mestre TA. Placebo and nocebo responses in other movement disorders besides Parkinson's disease: How much do we know? Mov Disord 2018; 33:1228-1235. [DOI: 10.1002/mds.113] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/20/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Joaquim J. Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa; Instituto de Medicina Molecular; Lisboa Portugal
| | - Claudia Trenkwalder
- Paracelsus-Elena Klinik, Center of Parkinsonism and Movement Disorders, Kassel; Department of Neurosurgery; University Medical Center; Göttingen Germany
| | - Tiago A. Mestre
- Parkinson's Disease and Movement Disorders Center, Division of Neurology, Department of Medicine, The Ottawa Hospital Research Institute; University of Ottawa; Ottawa ON Canada
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Watanabe H, Riku Y, Hara K, Kawabata K, Nakamura T, Ito M, Hirayama M, Yoshida M, Katsuno M, Sobue G. Clinical and Imaging Features of Multiple System Atrophy: Challenges for an Early and Clinically Definitive Diagnosis. J Mov Disord 2018; 11:107-120. [PMID: 30086614 PMCID: PMC6182302 DOI: 10.14802/jmd.18020] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/08/2018] [Accepted: 05/24/2018] [Indexed: 12/13/2022] Open
Abstract
Multiple system atrophy (MSA) is an adult-onset, progressive neurodegenerative disorder. Patients with MSA show various phenotypes during the course of their illness, including parkinsonism, cerebellar ataxia, autonomic failure, and pyramidal signs. Patients with MSA sometimes present with isolated autonomic failure or motor symptoms/ signs. The median duration from onset to the concomitant appearance of motor and autonomic symptoms is approximately 2 years but can range up to 14 years. As the presence of both motor and autonomic symptoms is essential for the current diagnostic criteria, early diagnosis is difficult when patients present with isolated autonomic failure or motor symptoms/signs. In contrast, patients with MSA may show severe autonomic failure and die before the presentation of motor symptoms/signs, which are currently required for the diagnosis of MSA. Recent studies have also revealed that patients with MSA may show nonsupporting features of MSA such as dementia, hallucinations, and vertical gaze palsy. To establish early diagnostic criteria and clinically definitive categorization for the successful development of disease-modifying therapy or symptomatic interventions for MSA, research should focus on the isolated phase and atypical symptoms to develop specific clinical, imaging, and fluid biomarkers that satisfy the requirements for objectivity, for semi- or quantitative measurements, and for uncomplicated, worldwide availability. Several novel techniques, such as automated compartmentalization of the brain into multiple parcels for the quantification of gray and white matter volumes on an individual basis and the visualization of α-synuclein and other candidate serum and cerebrospinal fluid biomarkers, may be promising for the early and clinically definitive diagnosis of MSA.
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Affiliation(s)
- Hirohisa Watanabe
- Brain and Mind Research Center, Nagoya University, Nagoya, Japan
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichi Riku
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Hara
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuya Kawabata
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomohiko Nakamura
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Masaaki Hirayama
- Department of Pathophysiological Laboratory Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mari Yoshida
- Institute for Medical Science of Aging, Aichi Medical University, Nagakute, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Gen Sobue
- Brain and Mind Research Center, Nagoya University, Nagoya, Japan
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Lopez-Cuina M, Foubert-Samier A, Tison F, Meissner WG. Present and future of disease-modifying therapies in multiple system atrophy. Auton Neurosci 2018; 211:31-38. [DOI: 10.1016/j.autneu.2017.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/22/2017] [Accepted: 12/29/2017] [Indexed: 10/18/2022]
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37
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Bower PG. Multiple system atrophy: Building a global community – 30 years of advocacy efforts. Auton Neurosci 2018; 211:39-42. [DOI: 10.1016/j.autneu.2017.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 11/16/2022]
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38
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Yulug B, Hanoglu L, Ozansoy M, Isık D, Kilic U, Kilic E, Schabitz WR. Therapeutic role of rifampicin in Alzheimer's disease. Psychiatry Clin Neurosci 2018; 72:152-159. [PMID: 29315976 DOI: 10.1111/pcn.12637] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/06/2017] [Accepted: 12/17/2017] [Indexed: 12/11/2022]
Abstract
Rifampicin exerts significant brain protective functions in multiple experimental models. Here we summarize the underlying mechanisms of the neuroprotective and pro-cognitive effects of rifampicin that are mediated by its anti-inflammatory, anti-tau, anti-amyloid, and cholinergic effects. Beyond suggesting that rifampicin shows strong brain protective effects in preclinical models of Alzheimer's disease, we also provide substantial clinical evidence for the neuroprotective and pro-cognitive effects of rifampicin. Future neuroimaging studies combined with clinical assessment scores are the following steps to be taken in this field of research.
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Affiliation(s)
- Burak Yulug
- Department of Neurology, Istanbul Medipol University, Istanbul, Turkey.,Department of Restorative and Regenerative Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Lütfü Hanoglu
- Department of Neurology, Istanbul Medipol University, Istanbul, Turkey.,Department of Restorative and Regenerative Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mehmet Ozansoy
- Department of Restorative and Regenerative Medicine, Istanbul Medipol University, Istanbul, Turkey.,Department of Physiology, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Dogan Isık
- Department of Psychiatry, Istanbul Medipol University, Istanbul, Turkey
| | - Ulkan Kilic
- Department of Medical Biology, Faculty of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Ertugrul Kilic
- Department of Restorative and Regenerative Medicine, Istanbul Medipol University, Istanbul, Turkey.,Department of Physiology, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Wolf Rüdiger Schabitz
- Department of Neurology, Bethel, EVKB, Bielefeld, University of Münster, Münster, Germany
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39
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McKay JH, Cheshire WP. First symptoms in multiple system atrophy. Clin Auton Res 2018; 28:215-221. [PMID: 29313153 PMCID: PMC5859695 DOI: 10.1007/s10286-017-0500-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/29/2017] [Indexed: 01/01/2023]
Abstract
Purpose The initial symptoms of multiple system atrophy (MSA) and, in particular, early autonomic symptoms, have received less attention than motor symptoms. Whereas pathognomonic motor signs are essential to diagnostic specificity, early symptoms important to recognition of a neurodegenerative disorder may be less apparent or diagnostically ambiguous. This observational study sought to identify the very earliest symptoms in the natural history of MSA. Methods Detailed clinical histories focusing on early symptoms were obtained from 30 subjects recently diagnosed with MSA. Historical data were correlated with neurological examinations and laboratory autonomic testing. Results Subjects’ mean age was 63.9 years. Ten were classified as having MSA-P and 20 MSA-C. The evaluations occurred 2.9 ± 0.4 months after diagnosis. The first symptom of MSA was autonomic in 22 (73%) and motor in 3 (10%) subjects (p < 0.0001). The most frequent first symptom was erectile failure, which occurred in all men beginning 4.2 ± 2.6 years prior to diagnosis. After erectile failure, postural lightheadness or fatigue following exercise, urinary urgency or hesitancy, and violent dream enactment behavior consistent with REM behavioral sleep disorder were the most frequent initial symptoms. Neither the order of symptom progression, which was highly variable, nor autonomic severity scores differentiated between MSA-P and MSA-C. Conclusions The first symptoms of MSA are frequently autonomic and may predate recognition of motor manifestations. Orthostatic hypotension and, in men, erectile failure are among the first symptoms that, when evaluated in the context of associated clinical findings, may facilitate accurate and earlier diagnosis.
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Affiliation(s)
- Jake H McKay
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL, 32224, USA
| | - William P Cheshire
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL, 32224, USA.
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40
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Translational therapies for multiple system atrophy: Bottlenecks and future directions. Auton Neurosci 2017; 211:7-14. [PMID: 29017831 DOI: 10.1016/j.autneu.2017.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/19/2017] [Accepted: 09/26/2017] [Indexed: 11/24/2022]
Abstract
Over the last decade a prominent amount of studies in preclinical transgenic models of multiple system atrophy (MSA) has been performed. These studies have helped understand mechanisms downstream to the α-synuclein oligodendroglial accumulation relevant to human MSA. However, the successful translation of the preclinical outcomes into a clinical trial has failed. Looking back, we can now identify possible confounders for the failure. Biomarkers of disease progression are mostly missing. Early diagnosis and initiation of therapeutic clinical trials is limited. The need of both proof-of-concept as well as clinically relevant preclinical study designs with clinically relevant timing and preclinical readouts is identified as a must in our translational efforts for MSA to date. Finally, improved clinical study designs with improved enrollment criteria, and measurement outcomes are warranted on the way to finding the successful therapeutic approach for MSA. This review provides an overview of experimental studies and clinical trials for MSA and the lessons learned over the last decade towards the identification of the cure for MSA.
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41
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Deutschländer AB, Ross OA, Dickson DW, Wszolek ZK. Atypical parkinsonian syndromes: a general neurologist's perspective. Eur J Neurol 2017; 25:41-58. [PMID: 28803444 DOI: 10.1111/ene.13412] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 08/10/2017] [Indexed: 12/14/2022]
Abstract
The differential diagnosis of atypical parkinsonian syndromes is challenging. These severe and often rapidly progressive neurodegenerative disorders are clinically heterogeneous and show significant phenotypic overlap. Here, clinical, imaging, neuropathological and genetic features of multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration and frontotemporal lobar degeneration (FTLD) are reviewed. The terms corticobasal degeneration and FTLD refer to pathologically confirmed cases of corticobasal syndrome and frontotemporal dementia (FTD). Frontotemporal lobar degeneration clinically presents as the behavioral variant FTD, semantic variant primary progressive aphasia (PPA), non-fluent agrammatic variant PPA, logopenic variant PPA and FTD associated with motor neuron disease. While progressive supranuclear palsy and corticobasal syndrome have been called Parkinson-plus syndromes in the past, they are now classified as FTD-related disorders, reflecting that they pathologically differ from α-synucleinopathies like multiple system atrophy and Parkinson disease. The contribution of genetic factors to atypical parkinsonian syndromes is increasingly recognized. Genes involved in the etiology of FTLD include MAPT, GRN and C9orf72. Novel neuroimaging techniques, including tau positron emission tomography imaging, are being investigated. Multimodal magnetic resonance imaging approaches and automated magnetic resonance imaging volume segmentation techniques are being evaluated for optimized differential diagnosis. Current treatment options are symptomatic, and disease modifying therapies are under active investigation.
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Affiliation(s)
- A B Deutschländer
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA.,Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL, USA
| | - O A Ross
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA.,Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL, USA
| | - D W Dickson
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - Z K Wszolek
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
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42
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Ono K. The Oligomer Hypothesis in α-Synucleinopathy. Neurochem Res 2017; 42:3362-3371. [PMID: 28828740 DOI: 10.1007/s11064-017-2382-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 12/16/2022]
Abstract
Lewy bodies and Lewy neurites in the brain constitute the main histopathological features of Parkinson's disease (PD) and dementia with Lewy bodies. They comprise amyloid-like fibrils composed of α-synuclein (αS), a small protein (~14 kDa). Because the aggregation of αS in the brain has been implicated as a critical step in the development of these diseases, the research for disease-modifying drugs has focused on modification of the αS aggregation process in the brain. Recent studies using synthetic αS peptides, a cell culture model, transgenic mice models, and human samples such as cerebrospinal fluids and the blood of PD patients have suggested that pre-fibrillar forms of αS (i.e., oligomers) are more critical than fibrillar forms (such as Lewy bodies) in the pathogenesis of α-synucleinopathies. Based on the accumulating evidence that oligomers play a central role in the pathogenesis of PD and other α-synucleinopathies (the "oligomer hypothesis"). This report reviews the recent findings regarding the oligomer hypothesis in the research of α-synucleinopathies.
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Affiliation(s)
- Kenjiro Ono
- Department of Neurology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan.
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43
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Alzheimer's disease as oligomeropathy. Neurochem Int 2017; 119:57-70. [PMID: 28821400 DOI: 10.1016/j.neuint.2017.08.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/30/2017] [Accepted: 08/13/2017] [Indexed: 12/21/2022]
Abstract
Alzheimer's disease (AD) is the most common age-related neurodegenerative disorder and is characterized by pathological aggregates of amyloid β-protein (Aβ) and tau protein. On the basis of genetic evidence, biochemical data, and animal models, Aβ has been suggested to be responsible for the pathogenesis of AD (the amyloid hypothesis). Aβ molecules tend to aggregate to form oligomers, protofibrils, and mature fibrils. Although mature fibrils in the final stage have been thought to be the cause of AD pathogenesis, recent studies using synthetic Aβ peptides, a cell culture model, Aβ precursor protein transgenic mice models, and human samples, such as cerebrospinal fluids and postmortem brains of AD patients, suggest that pre-fibrillar forms (oligomers of Aβ) are more deleterious than are extracellular fibril forms. Based on this recent evidence showing that oligomers have a central role in the pathogenesis of AD, the term "oligomeropathy" could be used to define AD and other protein-misfolding diseases. In this review, I discuss recent developments in the "oligomer hypothesis" including our research findings regarding the pathogenesis of AD.
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44
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Castro Caldas A, Levin J, Djaldetti R, Rascol O, Wenning G, Ferreira JJ. Critical appraisal of clinical trials in multiple system atrophy: Toward better quality. Mov Disord 2017; 32:1356-1364. [PMID: 28782838 DOI: 10.1002/mds.27080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/02/2017] [Accepted: 05/19/2017] [Indexed: 01/20/2023] Open
Abstract
Multiple system atrophy (MSA) is a rare neurodegenerative disease of undetermined cause. Although many clinical trials have been conducted, there is still no treatment that cures the disease or slows its progression. We sought to assess the clinical trials, methodology, and quality of reporting of clinical trails conducted in MSA patients. We conducted a systematic review of all trials with at least 1 MSA patient subject to any pharmacological/nonpharmacological interventions. Two independent reviewers evaluated the methodological characteristics and quality of reporting of trials. A total of 60 clinical trials were identified, including 1375 MSA patients. Of the trials, 51% (n = 31) were single-arm studies. A total of 28% (n = 17) had a parallel design, half of which (n = 13) were placebo controlled. Of the studies, 8 (13.3%) were conducted in a multicenter setting, 3 of which were responsible for 49.3% (n = 678) of the total included MSA patients. The description of primary outcomes was unclear in 60% (n = 40) of trials. Only 10 (16.7%) clinical trials clearly described the randomization process. Blinding of the participants, personnel, and outcome assessments were at high risk of bias in the majority of studies. The number of dropouts/withdrawals was high (n = 326, 23.4% among the included patients). Overall, the design and quality of reporting of the reviewed studies is unsatisfactory. The most frequent clinical trials were small and single centered. Inadequate reporting was related to the information on the randomization process, sequence generation, allocation concealment, blinding of participants, and sample size calculations. Although improved during the recent years, methodological quality and trial design need to be optimized to generate more informative results. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ana Castro Caldas
- Neurology Service, Department of Neurosciences, Hospital de Santa Maria, Lisbon, Portugal.,Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.,Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Johannes Levin
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany.,German Center for Neurodegenerative Diseases, Munich, Germany
| | - Ruth Djaldetti
- Department of Neurology, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
| | - Olivier Rascol
- Department of Neurosciences and Clinical Pharmacology, Reference Center for MSA, Clinical Investigation Center (CIC) 1436, and NeuroToul Center of Excellence in Neurodegeneration (COEN) Center, University of Toulouse, Institut national de la santé et de la recherche médicale (INSERM), University Hospital of Toulouse, Toulouse, France
| | - Gregor Wenning
- Department of Neurology, University Hospital, Innsbruck, Austria
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Laurens B, Vergnet S, Lopez MC, Foubert-Samier A, Tison F, Fernagut PO, Meissner WG. Multiple System Atrophy - State of the Art. Curr Neurol Neurosci Rep 2017; 17:41. [PMID: 28378233 DOI: 10.1007/s11910-017-0751-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Multiple system atrophy (MSA) is a rare and fatal neurodegenerative disorder that is characterized by a variable combination of parkinsonism, cerebellar impairment, and autonomic dysfunction. Some symptomatic treatments are available while neuroprotection or disease-modification remain unmet treatment needs. The pathologic hallmark is the accumulation of aggregated alpha-synuclein (α-syn) in oligodendrocytes forming glial cytoplasmic inclusions, which qualifies MSA as synucleinopathy together with Parkinson's disease and dementia with Lewy bodies. Despite progress in our understanding of the pathogenesis of MSA, the origin of α-syn aggregates in oligodendrocytes is still a matter of an ongoing debate. We critically review here studies published in the field over the past 5 years dealing with pathogenesis, genetics, clinical signs, biomarker for improving diagnostic accuracy, and treatment development.
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Affiliation(s)
- Brice Laurens
- Service de Neurologie, Hôpital Pellegrin, CHU de Bordeaux, 33000, Bordeaux, France
| | - Sylvain Vergnet
- Service de Neurologie, Hôpital Pellegrin, CHU de Bordeaux, 33000, Bordeaux, France
| | - Miguel Cuina Lopez
- Institut des Maladies Neurodégénératives, Univ. de Bordeaux, UMR 5293, 33000, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000, Bordeaux, France
| | - Alexandra Foubert-Samier
- Service de Neurologie, Hôpital Pellegrin, CHU de Bordeaux, 33000, Bordeaux, France.,Centre de Référence Maladie Rare AMS, Hôpital Pellegrin, CHU de Bordeaux, F-33076, Bordeaux, France
| | - François Tison
- Service de Neurologie, Hôpital Pellegrin, CHU de Bordeaux, 33000, Bordeaux, France.,Institut des Maladies Neurodégénératives, Univ. de Bordeaux, UMR 5293, 33000, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000, Bordeaux, France.,Centre de Référence Maladie Rare AMS, Hôpital Pellegrin, CHU de Bordeaux, F-33076, Bordeaux, France
| | - Pierre-Olivier Fernagut
- Institut des Maladies Neurodégénératives, Univ. de Bordeaux, UMR 5293, 33000, Bordeaux, France.,CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000, Bordeaux, France
| | - Wassilios G Meissner
- Service de Neurologie, Hôpital Pellegrin, CHU de Bordeaux, 33000, Bordeaux, France. .,Institut des Maladies Neurodégénératives, Univ. de Bordeaux, UMR 5293, 33000, Bordeaux, France. .,CNRS, Institut des Maladies Neurodégénératives, UMR 5293, 33000, Bordeaux, France. .,Centre de Référence Maladie Rare AMS, Hôpital Pellegrin, CHU de Bordeaux, F-33076, Bordeaux, France.
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46
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Abstract
Multiple system atrophy (MSA) is a devastating and fatal neurodegenerative disorder. The clinical presentation of this disease is highly variable, with parkinsonism, cerebellar ataxia and autonomic failure being the most common - and often debilitating - symptoms. These symptoms progress rapidly, and patients die from MSA-related complications after 9 years of symptom duration on average. Unfortunately, the course of the disease cannot be improved by drug or surgical treatment. In addition, symptomatic treatment options are currently limited, and therapeutic benefits are often only transient. Thus, further interventional studies of candidate disease-modifying and symptomatic therapies are essential to improve patient care. In the past 15 years, the understanding of MSA-specific requirements in trial methodology has improved, resulting in a substantial increase in high-quality interventional studies. In this Review, we discuss MSA risk factors, clinical presentation and neuropathology, and we provide a hypothesis on key pathophysiological events, a summary of recent randomized controlled trials, and an overview of ongoing international collaborations.
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47
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Valera E, Spencer B, Fields JA, Trinh I, Adame A, Mante M, Rockenstein E, Desplats P, Masliah E. Combination of alpha-synuclein immunotherapy with anti-inflammatory treatment in a transgenic mouse model of multiple system atrophy. Acta Neuropathol Commun 2017; 5:2. [PMID: 28057080 PMCID: PMC5217191 DOI: 10.1186/s40478-016-0409-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 12/18/2016] [Indexed: 11/10/2022] Open
Abstract
Multiple system atrophy (MSA) is a fatal neurodegenerative disorder characterized by the pathological accumulation of alpha-synuclein (α-syn) in oligodendrocytes. Therapeutic efforts to stop or delay the progression of MSA have yielded suboptimal results in clinical trials, and there are no efficient treatments currently available for MSA patients. We hypothesize that combining therapies targeting different aspects of the disease may lead to better clinical outcomes. To test this hypothesis, we combined the use of a single-chain antibody targeting α-syn modified for improved central nervous system penetration (CD5-D5) with an unconventional anti-inflammatory treatment (lenalidomide) in the myelin basic protein (MBP)-α-syn transgenic mouse model of MSA. While the use of either CD5-D5 or lenalidomide alone had positive effects on neuroinflammation and/or α-syn accumulation in this mouse model of MSA, the combination of both approaches yielded better results than each single treatment. The combined treatment reduced astrogliosis, microgliosis, soluble and aggregated α-syn levels, and partially improved behavioral deficits in MBP-α-syn transgenic mice. These effects were associated with an activation of the Akt signaling pathway, which may mediate cytoprotective effects downstream tumor necrosis factor alpha (TNFα). These results suggest that a strategic combination of treatments may improve the therapeutic outcome in trials for MSA and related neurodegenerative disorders.
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48
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Stefanova N, Wenning GK. Review: Multiple system atrophy: emerging targets for interventional therapies. Neuropathol Appl Neurobiol 2016; 42:20-32. [PMID: 26785838 PMCID: PMC4788141 DOI: 10.1111/nan.12304] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/13/2016] [Accepted: 01/20/2016] [Indexed: 12/21/2022]
Abstract
Multiple system atrophy (MSA) is a fatal orphan neurodegenerative disorder that manifests with rapidly progressive autonomic and motor dysfunction. The disease is characterized by the accumulation of α-synuclein fibrils in oligodendrocytes that form glial cytoplasmic inclusions, a neuropathological hallmark and central player in the pathogenesis of MSA. Here, we summarize the current knowledge on the etiopathogenesis and neuropathology of MSA. We discuss the role of α-synuclein pathology, microglial activation, oligodendroglial dysfunction and putative cell death mechanisms as candidate therapeutic targets in MSA.
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Affiliation(s)
- N Stefanova
- Division of Neurobiology, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - G K Wenning
- Division of Neurobiology, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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49
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Matsushima M, Yabe I, Oba K, Sakushima K, Mito Y, Takei A, Houzen H, Tsuzaka K, Yoshida K, Maruo Y, Sasaki H. Comparison of Different Symptom Assessment Scales for Multiple System Atrophy. THE CEREBELLUM 2016; 15:190-200. [PMID: 26093615 DOI: 10.1007/s12311-015-0686-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To identify the most sensitive scale for use in clinical trials on multiple system atrophy (MSA), a short and sensitive scale is needed for MSA clinical trials. Potential candidates are the Unified MSA Rating Scale (UMSARS), Scale for the Assessment and Rating of Ataxia (SARA), Berg Balance Scale (BBS), MSA Health-Related Quality of Life scale (MSA-QoL), and Scales for Outcomes in Parkinson's Disease-Autonomic questionnaire (SCOPA-AUT). We enrolled patients with MSA from eight hospitals in Hokkaido, Japan. Board-certified neurologists assessed each patient at 6-month intervals and scored them on the UMSARS, SARA, BBS, MSA-QoL, and SCOPA-AUT. Score changes were evaluated using the standardized response mean (SRM). The correlation between disease duration and each score was examined. The first evaluation was conducted on 85 patients (60 patients with MSA cerebellar ataxia dominant subtype [MSA-C] and 25 patients with MSA Parkinsonism-dominant subtype [MSA-P]). Sixty-nine patients were examined after 6 months and 63 patients after 12 months. The UMSARS Part 4 had the largest SRM after 6 months and the SARA after 12 months. SRMs for MSA-P, the shorter duration group, and the early-onset group were larger than were those for MSA-C, the longer duration group, and the late-onset group. SRMs for items regarding skilled hand activities, walking, and standing were relatively large. Our study indicates that the UMSARS (parts 2 and 4), SARA, and BBS are sensitive scales for evaluating MSA progression over 12 months. Items with large SRMs effectively evaluated short-term changes.
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Affiliation(s)
- Masaaki Matsushima
- Department of Neurology, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Ichiro Yabe
- Department of Neurology, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Koji Oba
- Research and Clinical Trial Center, Hokkaido University Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Department of Biostatistics, School of Public Health, Graduate School of Medicine, and Interfaculty Initiative in Information Studies, The University of Tokyo, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Ken Sakushima
- Department of Neurology, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yasunori Mito
- Sapporo City General Hospital, 1-1 Kita-11, Nishi-13, Chuo-ku, Sapporo, 060-8604, Japan
| | - Asako Takei
- Hokuyukai Neurological Hospital, Niju-Yon-Ken 2-2-4-30, Nishi-ku, Sapporo, 063-0802, Japan
| | - Hideki Houzen
- Obihiro Kosei Hospital, Nishi-6, Minami-8, Obihiro, 080-0016, Japan
| | - Kazufumi Tsuzaka
- Kushiro Rosai Hospital, 13-23 Nakazono-cho, Kushiro, 085-8533, Japan
| | - Kazuto Yoshida
- Japanese Red Cross Asahikawa Hospital, 1-1 Akebono, Asahikawa, 070-8530, Japan
| | - Yasunori Maruo
- Hakodate Municipal Hospital, 1-10-1 Minato-cho, Hakodate, 041-8680, Japan
| | - Hidenao Sasaki
- Department of Neurology, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
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50
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Abstract
OPINION STATEMENT Treatment of patients with multiple system atrophy (MSA) is complex and purely symptomatic to date. No disease-modifying treatment is available so far, leaving a survival time of usually less than 10 years after diagnosis is made. Clinically, two forms of movement disorders characterize this disease, either a hypokinetic rigid parkinsonian movement disorder in MSA of the parkinsonian type or ataxia in MSA of the cerebellar type. In both variants of the disease, autonomic symptoms are mandatory for establishing the diagnosis of MSA. While hypokinetic rigid symptoms of patients with MSA of the parkinsonian type can respond to some extent to dopaminergic treatment, no effective symptomatic treatment for the cerebellar symptoms is available so far. Particular attention should be paid to autonomic symptoms, as these symptoms are known to strongly affect the patients' quality of life. Here, we discuss the current state of the art in MSA treatment.
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Affiliation(s)
- Sylvia Maaß
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) and Klinik für Neurologie, Klinikum rechts der Isar, Technische Universität München, Feodor-Lynen Str. 17, 81377, Munich, Germany
| | - Johannes Levin
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) and Klinik für Neurologie, Klinikum rechts der Isar, Technische Universität München, Feodor-Lynen Str. 17, 81377, Munich, Germany.,Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum der Universität-Großhadern, Marchioninistraße 15, 81377, Munich, Germany
| | - Günter Höglinger
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) and Klinik für Neurologie, Klinikum rechts der Isar, Technische Universität München, Feodor-Lynen Str. 17, 81377, Munich, Germany.
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