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O’Shea DM, Arkhipenko A, Galasko D, Goldman JG, Sheikh ZH, Petrides G, Toledo JB, Galvin JE. Practical use of DAT SPECT imaging in diagnosing dementia with Lewy bodies: a US perspective of current guidelines and future directions. Front Neurol 2024; 15:1395413. [PMID: 38711561 PMCID: PMC11073567 DOI: 10.3389/fneur.2024.1395413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/25/2024] [Indexed: 05/08/2024] Open
Abstract
Background Diagnosing Dementia with Lewy Bodies (DLB) remains a challenge in clinical practice. The use of 123I-ioflupane (DaTscan™) SPECT imaging, which detects reduced dopamine transporter (DAT) uptake-a key biomarker in DLB diagnosis-could improve diagnostic accuracy. However, DAT imaging is underutilized despite its potential, contributing to delays and suboptimal patient management. Methods This review evaluates DLB diagnostic practices and challenges faced within the U.S. by synthesizing information from current literature, consensus guidelines, expert opinions, and recent updates on DaTscan FDA filings. It contrasts DAT SPECT with alternative biomarkers, provides recommendations for when DAT SPECT imaging may be indicated and discusses the potential of emerging biomarkers in enhancing diagnostic approaches. Results The radiopharmaceutical 123I-ioflupane for SPECT imaging was initially approved in Europe (2000) and later in the US (2011) for Parkinsonism/Essential Tremor. Its application was extended in 2022 to include the diagnosis of DLB. DaTscan's diagnostic efficacy for DLB, with its sensitivity, specificity, and predictive values, confirms its clinical utility. However, US implementation faces challenges such as insurance barriers, costs, access issues, and regional availability disparities. Conclusion 123I-ioflupane SPECT Imaging is indicated for DLB diagnosis and differential diagnosis of Alzheimer's Disease, particularly in uncertain cases. Addressing diagnostic obstacles and enhancing physician-patient education could improve and expedite DLB diagnosis. Collaborative efforts among neurologists, geriatric psychiatrists, psychologists, and memory clinic staff are key to increasing diagnostic accuracy and care in DLB management.
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Affiliation(s)
- Deirdre M. O’Shea
- Department of Neurology, Comprehensive Center for Brain Health, University of Miami, Miller School of Medicine, Coral Gables, FL, United States
| | | | - Douglas Galasko
- Department of Neurosciences, UC San Diego, San Diego, CA, United States
| | - Jennifer G. Goldman
- JPG Enterprises LLC, Chicago, IL, United States
- Barrow Neurological Institute, Phoenix, AZ, United States
| | | | - George Petrides
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Jon B. Toledo
- Nantz National Alzheimer Center, Stanley Appel Department of Neurology, Houston Methodist Hospital, Houston, TX, United States
| | - James E. Galvin
- Department of Neurology, Comprehensive Center for Brain Health, University of Miami, Miller School of Medicine, Coral Gables, FL, United States
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Gibbons CH, Levine T, Adler C, Bellaire B, Wang N, Stohl J, Agarwal P, Aldridge GM, Barboi A, Evidente VGH, Galasko D, Geschwind MD, Gonzalez-Duarte A, Gil R, Gudesblatt M, Isaacson SH, Kaufmann H, Khemani P, Kumar R, Lamotte G, Liu AJ, McFarland NR, Miglis M, Reynolds A, Sahagian GA, Saint-Hillaire MH, Schwartzbard JB, Singer W, Soileau MJ, Vernino S, Yerstein O, Freeman R. Skin Biopsy Detection of Phosphorylated α-Synuclein in Patients With Synucleinopathies. JAMA 2024; 331:1298-1306. [PMID: 38506839 PMCID: PMC10955354 DOI: 10.1001/jama.2024.0792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/18/2024] [Indexed: 03/21/2024]
Abstract
Importance Finding a reliable diagnostic biomarker for the disorders collectively known as synucleinopathies (Parkinson disease [PD], dementia with Lewy bodies [DLB], multiple system atrophy [MSA], and pure autonomic failure [PAF]) is an urgent unmet need. Immunohistochemical detection of cutaneous phosphorylated α-synuclein may be a sensitive and specific clinical test for the diagnosis of synucleinopathies. Objective To evaluate the positivity rate of cutaneous α-synuclein deposition in patients with PD, DLB, MSA, and PAF. Design, Setting, and Participants This blinded, 30-site, cross-sectional study of academic and community-based neurology practices conducted from February 2021 through March 2023 included patients aged 40 to 99 years with a clinical diagnosis of PD, DLB, MSA, or PAF based on clinical consensus criteria and confirmed by an expert review panel and control participants aged 40 to 99 years with no history of examination findings or symptoms suggestive of a synucleinopathy or neurodegenerative disease. All participants completed detailed neurologic examinations and disease-specific questionnaires and underwent skin biopsy for detection of phosphorylated α-synuclein. An expert review panel blinded to pathologic data determined the final participant diagnosis. Exposure Skin biopsy for detection of phosphorylated α-synuclein. Main Outcomes Rates of detection of cutaneous α-synuclein in patients with PD, MSA, DLB, and PAF and controls without synucleinopathy. Results Of 428 enrolled participants, 343 were included in the primary analysis (mean [SD] age, 69.5 [9.1] years; 175 [51.0%] male); 223 met the consensus criteria for a synucleinopathy and 120 met criteria as controls after expert panel review. The proportions of individuals with cutaneous phosphorylated α-synuclein detected by skin biopsy were 92.7% (89 of 96) with PD, 98.2% (54 of 55) with MSA, 96.0% (48 of 50) with DLB, and 100% (22 of 22) with PAF; 3.3% (4 of 120) of controls had cutaneous phosphorylated α-synuclein detected. Conclusions and Relevance In this cross-sectional study, a high proportion of individuals meeting clinical consensus criteria for PD, DLB, MSA, and PAF had phosphorylated α-synuclein detected by skin biopsy. Further research is needed in unselected clinical populations to externally validate the findings and fully characterize the potential role of skin biopsy detection of phosphorylated α-synuclein in clinical care.
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Affiliation(s)
- Christopher H. Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Todd Levine
- HonorHealth Neurology, Scottsdale, Arizona
- CND Life Sciences, Scottsdale, Arizona
| | - Charles Adler
- Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | | | - Ningshan Wang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | - Georgina M. Aldridge
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City
| | - Alexandru Barboi
- Department of Neurology, Northshore University Health System, Glenview, Illinois
| | | | - Douglas Galasko
- Department of Neurology, University of California, San Diego
| | | | | | - Ramon Gil
- Parkinson’s Disease Treatment Center of Southwest Florida, Port Charlotte
| | - Mark Gudesblatt
- Department of Neurology, New York University Grossman Long Island School of Medicine, New York
| | - Stuart H. Isaacson
- Parkinson’s Disease and Movement Disorders Center of Boca Raton, Boca Raton, Florida
| | - Horacio Kaufmann
- Department of Neurology, New York University Grossman School of Medicine, New York
| | - Pravin Khemani
- Department of Neurology, Swedish Medical Center, Seattle, Washington
| | - Rajeev Kumar
- Rocky Mountain Movement Disorders Center, Englewood, Colorado
| | | | - Andy J. Liu
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | | | - Mitchell Miglis
- Department of Neurology, Stanford University Medical Center, Palo Alto, California
| | | | | | | | | | - Wolfgang Singer
- Department of Neurology, Mayo Clinic Rochester, Rochester, New York
| | | | - Steven Vernino
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas
| | - Oleg Yerstein
- Department of Neurology, Lahey Clinic, Burlington, Massachusetts
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Agarwal K, Backler W, Bayram E, Bloom L, Boeve BF, Cha J, Denslow M, Ferman TJ, Galasko D, Galvin JE, Gomperts SN, Irizarry MC, Kantarci K, Kaushik H, Kietlinski M, Koenig A, Leverenz JB, McKeith I, McLean PJ, Montine TJ, Moose SO, O'Brien JT, Panier V, Ramanathan S, Ringel MS, Scholz SW, Small J, Sperling RA, Taylor A, Taylor J, Ward RA, Witten L, Hyman BT. Lewy body dementia: Overcoming barriers and identifying solutions. Alzheimers Dement 2024; 20:2298-2308. [PMID: 38265159 PMCID: PMC10942666 DOI: 10.1002/alz.13674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 01/25/2024]
Abstract
Despite its high prevalence among dementias, Lewy body dementia (LBD) remains poorly understood with a limited, albeit growing, evidence base. The public-health burden that LBD imposes is worsened by overlapping pathologies, which contribute to misdiagnosis, and lack of treatments. For this report, we gathered and analyzed public-domain information on advocacy, funding, research outputs, and the therapeutic pipeline to identify gaps in each of these key elements. To further understand the current gaps, we also conducted interviews with leading experts in regulatory/governmental agencies, LBD advocacy, academic research, and biopharmaceutical research, as well as with funding sources. We identified wide gaps across the entire landscape, the most critical being in research. Many of the experts participated in a workshop to discuss the prioritization of research areas with a view to accelerating therapeutic development and improving patient care. This white paper outlines the opportunities for bridging the major LBD gaps and creates the framework for collaboration in that endeavor. HIGHLIGHTS: A group representing academia, government, industry, and consulting expertise was convened to discuss current progress in Dementia with Lewy Body care and research. Consideration of expert opinion,natural language processing of the literature as well as publicly available data bases, and Delphi inspired discussion led to a proposed consensus document of priorities for the field.
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Affiliation(s)
| | | | - Ece Bayram
- Parkinson and Other Movement Disorders CenterDepartment of NeurosciencesUniversity of California San DiegoLa JollaCaliforniaUSA
| | | | | | | | - Maria Denslow
- Alzheimer Disease and Brain HealthEisai, Inc.NutleyNew JerseyUSA
| | - Tanis J. Ferman
- Department of Psychiatry and PsychologyMayo ClinicJacksonvilleFloridaUSA
| | - Douglas Galasko
- Department of Neurosciencesand Shiley‐Marcos Alzheimer's Disease Research CenterUC San DiegoLa JollaCaliforniaUSA
| | - James E. Galvin
- Department of NeurologyComprehensive Center for Brain HealthUniversity of Miami Miller School of MedicineBoca RatonFloridaUSA
| | | | | | - Kejal Kantarci
- Department of RadiologyDivision of NeuroradiologyMayo Clinic RochesterRochesterMinnesotaUSA
| | | | | | | | - James B. Leverenz
- Cleveland Lou Ruvo Center for Brain HealthNeurological InstituteCleveland ClinicClevelandOhioUSA
| | - Ian McKeith
- Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
| | | | | | | | - John T. O'Brien
- Department of PsychiatryUniversity of Cambridge School of Clinical MedicineCambridgeUK
| | | | - Sharad Ramanathan
- Departments of Molecular and Cell BiologyStem Cell and Regenerative Biology and Applied PhysicsHarvard UniversityCambridgeMassachusettsUSA
| | | | - Sonja W. Scholz
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
- Department of NeurologyJohns Hopkins University Medical CenterBaltimoreMarylandUSA
| | | | - Reisa A. Sperling
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
- Department of NeurologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Rebecca A. Ward
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Lisa Witten
- The Boston Consulting GroupBostonMassachusettsUSA
| | - Bradley T. Hyman
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
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Tolea MI, Ezzeddine R, Camacho S, Galvin JE. Emerging drugs for dementia with Lewy Bodies: a review of Phase II & III trials. Expert Opin Emerg Drugs 2023; 28:167-180. [PMID: 37531299 DOI: 10.1080/14728214.2023.2244425] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Despite faster cognitive decline and greater negative impact on patients and family caregivers, drug development efforts in Dementia with Lewy Bodies (DLB) fall behind those for Alzheimer's Disease (AD). Current off-label drug DLB treatment options are limited to symptomatic agents developed to address cognitive deficits in AD, motor deficits in Parkinson's Disease, or behavioral symptoms in psychiatric disease. Aided by recent improvements in DLB diagnosis, a new focus on the development of disease-modifying agents (DMA) is emerging. AREAS COVERED Driven by evidence supporting different pathological mechanisms in DLB and PDD, this review assesses the evidence on symptomatic drug treatments and describes current efforts in DMA development in DLB. Specifically, our goals were to: (1) review evidence supporting the use of symptomatic drug treatments in DLB; (2) review the current DMA pipeline in DLB with a focus on Phase II and III clinical trials; and (3) identify potential issues with the development of DMA in DLB. Included in this review were completed and ongoing drug clinical trials in DLB registered on ClinicalTrials.gov (no time limits set for the search) or disseminated at the 2023 international conference on Clinical Trials in AD. Drug clinical trials registered in non-US clinical trial registries were not included. EXPERT OPINION Adoption of current symptomatic drug treatments used off-label in DLB relied on efficacy of benefits in other disorders rather than evidence from randomized controlled clinical trials. Symptoms remain difficult to manage. Several DMA drugs are currently being evaluated as either repurposing candidates or novel small molecules. Continued improvement in methodological aspects including development of DLB-specific outcome measures and biomarkers is needed to move the field of DMA drug development forward.
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Affiliation(s)
- Magdalena I Tolea
- Comprehensive Center for Brain Health, Lewy Body Dementia Research Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Reem Ezzeddine
- Comprehensive Center for Brain Health, Lewy Body Dementia Research Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Simone Camacho
- Comprehensive Center for Brain Health, Lewy Body Dementia Research Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James E Galvin
- Comprehensive Center for Brain Health, Lewy Body Dementia Research Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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Goolla M, Cheshire WP, Ross OA, Kondru N. Diagnosing multiple system atrophy: current clinical guidance and emerging molecular biomarkers. Front Neurol 2023; 14:1210220. [PMID: 37840912 PMCID: PMC10570409 DOI: 10.3389/fneur.2023.1210220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Multiple system atrophy (MSA) is a rare and progressive neurodegenerative disorder characterized by motor and autonomic dysfunction. Accurate and early diagnosis of MSA is challenging due to its clinical similarity with other neurodegenerative disorders, such as Parkinson's disease and atypical parkinsonian disorders. Currently, MSA diagnosis is based on clinical criteria drawing from the patient's symptoms, lack of response to levodopa therapy, neuroimaging studies, and exclusion of other diseases. However, these methods have limitations in sensitivity and specificity. Recent advances in molecular biomarker research, such as α-synuclein protein amplification assays (RT-QuIC) and other biomarkers in cerebrospinal fluid and blood, have shown promise in improving the diagnosis of MSA. Additionally, these biomarkers could also serve as targets for developing disease-modifying therapies and monitoring treatment response. In this review, we provide an overview of the clinical syndrome of MSA and discuss the current diagnostic criteria, limitations of current diagnostic methods, and emerging molecular biomarkers that offer hope for improving the accuracy and early detection of MSA.
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Affiliation(s)
- Meghana Goolla
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, United States
- Department of Surgery, University of Illinois, Chicago, IL, United States
| | | | - Owen A. Ross
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, United States
- Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL, United States
- Department of Biology, University of North Florida, Jacksonville, FL, United States
| | - Naveen Kondru
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, United States
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Chompoopong P, Reiter-Campeau S. Recent updates in autonomic research: orthostatic hypotension and cognitive function in Parkinson disease and multiple system atrophy, the skin as a window into synuclein pathology, and RFC1 repeat expansions in hereditary sensory autonomic neuropathies. Clin Auton Res 2023; 33:387-389. [PMID: 37493897 DOI: 10.1007/s10286-023-00968-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
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Coughlin DG, Irwin DJ. Fluid and Biopsy Based Biomarkers in Parkinson's Disease. Neurotherapeutics 2023; 20:932-954. [PMID: 37138160 PMCID: PMC10457253 DOI: 10.1007/s13311-023-01379-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/05/2023] Open
Abstract
Several advances in fluid and tissue-based biomarkers for use in Parkinson's disease (PD) and other synucleinopathies have been made in the last several years. While work continues on species of alpha-synuclein (aSyn) and other proteins which can be measured from spinal fluid and plasma samples, immunohistochemistry and immunofluorescence from peripheral tissue biopsies and alpha-synuclein seeding amplification assays (aSyn-SAA: including real-time quaking induced conversion (RT-QuIC) and protein misfolding cyclic amplification (PMCA)) now offer a crucial advancement in their ability to identify aSyn species in PD patients in a categorical fashion (i.e., of aSyn + vs aSyn -); to augment clinical diagnosis however, aSyn-specific assays that have quantitative relevance to pathological burden remain an unmet need. Alzheimer's disease (AD) co-pathology is commonly found postmortem in PD, especially in those who develop dementia, and dementia with Lewy bodies (DLB). Biofluid biomarkers for tau and amyloid beta species can detect AD co-pathology in PD and DLB, which does have relevance for prognosis, but further work is needed to understand the interplay of aSyn tau, amyloid beta, and other pathological changes to generate comprehensive biomarker profiles for patients in a manner translatable to clinical trial design and individualized therapies.
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Affiliation(s)
- David G Coughlin
- Department of Neurosciences, University of California San Diego, 9444 Medical Center Drive, ECOB 03-021, MCC 0886, La Jolla, CA, 92037, USA.
| | - David J Irwin
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Cheshire WP. The grand challenge of autonomic disorders. Front Neurol 2022; 13:1052137. [PMID: 36388207 PMCID: PMC9663922 DOI: 10.3389/fneur.2022.1052137] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022] Open
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Hovaguimian A. Dysautonomia. Neurol Clin 2022; 41:193-213. [DOI: 10.1016/j.ncl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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