Emerging therapies in the pharmacological treatment of Parkinson's disease

Apomorphine infusion in advanced Parkinson's patients with subthalamic stimulation contraindications

BACKGROUND

The efficacy of continuous subcutaneous apomorphine infusion (APO) has been evaluated in advanced Parkinson's disease in several open-label studies but never in a population of patients for whom subthalamic nucleus deep brain stimulation (STN-DBS) was contraindicated.

METHODS

The aim of this study was to evaluate the efficacy and cognitive safety of APO at 12-month follow-up in 23 advanced parkinsonian patients (mean age: 62.3 years; mean disease duration: 13.9 years) whose dopa-resistant axial motor symptoms and/or cognitive decline constituted contraindications for STN-DBS. Their motor and cognitive status were evaluated before APO and 12 months afterwards.

RESULTS

After one year, patients expressed high levels of satisfaction, with a mean rating on the Visual Analog Scale of 52.8% under APO. Daily OFF time, recorded in a 24-h diary, was reduced by 36% and ON time improved by 48%. There was a significant reduction (-26%) in mean oral levodopa equivalent dose. Dopa-resistant axial symptoms and neuropsychological performance remained stable. No adverse event was noted and none of the patients needed to take clozapine at any time.

CONCLUSIONS

APO is both safe and effective in advanced parkinsonian patients with untreatable motor fluctuations, for whom STN-DBS is contraindicated due to dopa-resistant axial motor symptoms and/or cognitive decline. As such, it should be regarded as a viable alternative for these patients.

Treatment of levodopa-induced motor complications

Chronic levodopa treatment for Parkinson's disease patients is frequently associated with the development of motor complications such as end-of-dose wearing-off and dyskinesias. In this review, we provide an overview of the strategies available for dealing with these problems. Medical management includes manipulation of levodopa dosing to establish the optimum treatment schedule, improving levodopa absorption, catechol-O-methyl transferase-inhibition (COMT), Monoamine oxidase-B (MAO-B) inhibition, dopaminergic agonists, amantadine, and continuous dopaminergic infusions. Surgical procedures and particularly deep brain stimulation are also reviewed. It should be noted that none of these treatments has been shown to provide anti-parkinsonian efficacy that is greater than what can be achieved with levodopa. We highlight the importance of initiating therapy with a treatment strategy that reduces the risk that a Parkinson's disease patient will develop motor complications in the first place. Key Words: Advanced PD, dyskinesias, motor fluctuations, levodopa, dopamine agonists, COMT inhibitors, MAO-B inhibitors.

Multifunctional receptor-directed drugs for disorders of the central nervous system

The marked decline in FDA-approved new drug candidates in recent years suggests the possibility that the "low-hanging fruit" has been almost entirely harvested. This might be particularly applicable to drugs acting on the central nervous system. Fortunately, there are several examples extant for the utility of multifunctional drugs, compounds, or drug mixtures that act on multiple additive or synergistic targets. However, to exploit this approach may require the willingness to consider the possibility that drug targets might be addressed by molecules of rather low specificity and moderate potency. The expectation is that single target molecules with high specificity might not have access to complex interacting neural pathways, and that moderate potency could engender fewer off-target side effects. Though novel compounds might be developed by combining the active functional groups of two or more drug molecules, the approach still lends itself to high throughput screening of large chemical libraries. Multifunctional compounds might be designed with the ability to: 1) offer both palliative and disease modifying actions, 2) act on targets that produce additive or synergistic therapeutic responses, 3) simultaneously evoke a therapeutic response at the desired target and prevent an undesired response mediated by an alternate target, 4) allow one component to promote the drugable characteristics (e.g., brain penetration) of the therapeutic component, and 5) prolong the duration of effectiveness of one compound by contributing the pharmacodynamic actions of another. The author takes the liberty to include examples of the situations just mentioned from studies in his laboratory in the following discussion.

Rasagiline-associated motor improvement in PD occurs without worsening of cognitive and behavioral symptoms

BACKGROUND

Cognitive and behavioral adverse events (AEs) such as hallucinations, confusion, depression, somnolence and other sleep disorders commonly limit effective management of motor symptoms in PD. Rasagiline (N-propargyl-1(R)-aminoindan) mesylate is a novel, second-generation, selective, irreversible monoamine oxidase type B inhibitor, demonstrated in monotherapy and adjunctive trials to be effective for PD with excellent tolerability.

METHODS

The occurrence of cognitive and behavioral AEs and the change from baseline in the Unified Parkinson's Disease Rating Scale (UPDRS) part I mental subscores were reviewed in two multicenter, randomized, placebo-controlled, 26-week trials of rasagiline for early and moderate-to-advanced patients with PD. The UPDRS is a multi-item rating scale specific to PD; part I rates the patient's intellectual impairment, thought disorders, depression and motivation/initiative.

RESULTS

The TEMPO study evaluated rasagiline monotherapy in early PD patients (n=404). The PRESTO study evaluated rasagiline as adjunctive therapy in moderate-to-advanced PD patients with motor complications who were receiving optimized levodopa/carbidopa (n=472). In the analysis of adverse event reporting for both studies, no cognitive and behavioral AE in either the rasagiline 1 mg or placebo groups exceeded 10% of the study population and the frequency differences between rasagiline 1 mg and placebo never exceeded 3%. There was no adverse effect on the UPDRS mental subscore relative to placebo in either of the two studies.

CONCLUSION

Rasagiline 1 mg once daily improves PD symptoms and motor fluctuations in early and moderate-to-advanced PD patients without causing significant cognitive and behavioral AE or adverse changes in mentation, behavior and mood.

Geldanamycin Induces Heat Shock Protein 70 and Protects against MPTP-induced Dopaminergic Neurotoxicity in Mice

As key molecular chaperone proteins, heat shock proteins (HSPs) represent an important cellular protective mechanism against neuronal cell death in various models of neurological disorders. In this study, we investigated the effect as well as the molecular mechanism of geldanamycin (GA), an inhibitor of Hsp90, on 1-methyl-4-pheny-1,2,3,6-tetrahydropyridine (MPTP)-induced dopaminergic neurotoxicity, a mouse model of Parkinson disease. Neurochemical analysis showed that pretreatment with GA (via intracerebral ventricular injection 24 h prior to MPTP treatment) increased residual dopamine content and tyrosine hydroxylase immunoreactivity in the striatum 24 h after MPTP treatment. To dissect out the molecular mechanism underlying this neuroprotection, we showed that the GA-mediated protection against MPTP was associated with a reduction of cytosolic Hsp90 and an increase in Hsp70, with no significant changes in Hsp40 and Hsp25 levels. Furthermore, in parallel with the induction of Hsp70, striatal nuclear HSF1 levels and HSF1 binding to heat shock element sites in the Hsp70 promoter were significantly enhanced by the GA pretreatment. Together these results suggested that the molecular cascade leading to the induction of Hsp70 is critical to the neuroprotection afforded by GA against MPTP-induced neurotoxicity in the brain and that pharmacological inhibition of Hsp90 may represent a potential therapeutic strategy for Parkinson disease.

Prevention and treatment of motor fluctuations

The symptoms of Parkinson's disease can become increasingly difficult to control as the disease advances, particularly with the development of motor complications, such as end-of-dose wearing-off and dyskinesias, following long-term therapy. At this stage, the patient is frequently referred to a Parkinson's disease specialist for advice on the management of their disease. In this review we provide an overview of the Parkinson's disease specialist's strategies for coping with such problems. This includes strategy to prevent or delay motor fluctuations and the concept of the long duration response. The paper also includes establishing the optimum and most rational levodopa treatment schedule, improving levodopa absorption, use of COMT-inhibition, the addition of oral dopaminergic agonists, and the use of subcutaneous injections or infusions of apomorphine or lisuride. Finally, we highlight the increasing importance of treatment strategies that stimulate dopamine receptors in a more continuous, less pulsatile manner as a way of reducing the risk of developing treatment-associated motor complications.

LY503430, a novel alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid receptor potentiator with functional, neuroprotective and neurotrophic effects in rodent models of Parkinson's disease

Glutamate is the major excitatory transmitter in the brain. Recent developments in the molecular biology and pharmacology of the alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) subtype of glutamate receptors have led to the discovery of selective, potent, and systemically active AMPA receptor potentiators. These molecules enhance synaptic transmission and play important roles in plasticity and cognitive processes. In the present study, we first characterized a novel AMPA receptor potentiator, (R)-4'-[1-fluoro-1-methyl-2-(propane-2-sulfonylamino)-ethyl]-biphenyl-4-carboxylic acid methylamide (LY503430), on recombinant human GLUA1-4 and native preparations in vitro and then evaluated the potential neuroprotective effects of the molecule in rodent models of Parkinson's disease. Results indicated that submicromolar concentrations of LY503430 selectively enhanced glutamate-induced calcium influx into human embryonic kidney 293 cells transfected with human GLUA1, GLUA2, GLUA3, or GLUA4 AMPA receptors. The molecule also potentiated AMPA-mediated responses in native cortical, hippocampal, and substantia nigra neurons. We also report here that LY503430 provided dose-dependent functional and histological protection in animal models of Parkinson's disease. The neurotoxicity after unilateral infusion of 6-hydroxydopamine into either the substantia nigra or the striatum of rats and that after systemic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in mice were reduced. Interestingly, LY503430 also had neurotrophic actions on functional and histological outcomes when treatment was delayed until well after (6 or 14 days) the lesion was established. LY503430 also produced some increase in brain-derived neurotrophic factor in the substantia nigra and a dose-dependent increases in growth associated protein-43 (GAP-43) expression in the striatum. Therefore, we propose that AMPA receptor potentiators offer the potential of a new disease modifying therapy for Parkinson's disease.

Potential use of stem cells in neuroreplacement therapies for neurodegenerative diseases

The use of stem cells for neuroreplacement therapy is no longer science fiction--it is science fact. We have succeeded in the development of neural and mesenchymal stem cell transplantation to produce neural cells in the brain. We have also seen improvement in cognitive function following stem cell transplantation in a memory-impaired aged animal model. These results promise a bright future for stem cell therapies in neurodegenerative diseases. Before we begin to think about clinical applications beyond the present preclinical studies, we have to consider the pathophysiological environment of individual diseases and weigh the factors that affect stem cell biology. Here, I not only review potential therapeutic applications of stem cell strategies in neurodegenerative diseases, but also discuss stem cell biology regarding factors that are altered under disease conditions.