Activity of Choline Alphoscerate on Adult-Onset Cognitive Dysfunctions: A Systematic Review and Meta-Analysis

Safety evaluation of alpha-glycerylphosphorylcholine as a novel food

To evaluate the safety of alpha-glycerylphosphorylcholine (α-GPC) as a novel food, the study of acute oral toxicity, subchronic toxicity, teratogenic toxicity and genotoxicity were conducted. In acute oral toxicity, no toxic effects were observed in rats of both genders administrated 10.0 g/kg BW α-GPC. In 90-day oral toxicity, female high-dose group (2,000 mg/kg) had lower body weight, body weight gain, empty stomach body weight, total protein (TP), albumin (ALB), and higher alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) in contrast to control group. In teratogenic toxicity, the body weights of pregnant rats on the 9th day (d9), the 12th day (d12), the 15th day (d15), and the 20th day (d20), body weight gains, and net body weight gains in high-dose group (2,000 mg/kg) decreased, the other parameters had no difference compared to control group. In genotoxicity tests (Mammalian erythrocyte micronucleus, Chromosome aberration and Ames test), all dose groups didn't display significant change compared with negative control group. Based on above results, α-GPC is actually low hazard novel food, has a NOAEL of 1,000 mg/kg BW for female rats and 2,000 mg/kg BW for male rats following 13-week oral exposure, has a NOAEL of 1,000 mg/kg BW for pregnant rats and 2,000 mg/kg BW for fetal rats in teratogenic toxicity, has no genotoxicity in vitro or in vivo.

Genetic architecture of cerebrospinal fluid and brain metabolite levels and the genetic colocalization of metabolites with human traits

Brain metabolism perturbation can contribute to traits and diseases. We conducted a genome-wide association study for cerebrospinal fluid (CSF) and brain metabolite levels, identifying 205 independent associations (47.3% new signals, containing 11 new loci) for 139 CSF metabolites, and 32 independent associations (43.8% new signals, containing 4 new loci) for 31 brain metabolites. Of these, 96.9% (CSF) and 71.4% (brain) of the new signals belonged to previously analyzed metabolites in blood or urine. We integrated the metabolite quantitative trait loci (MQTLs) with 23 neurological, psychiatric and common human traits and diseases through colocalization to identify metabolites and biological processes implicated in these phenotypes. Combining CSF and brain, we identified 71 metabolite-trait associations, such as glycerophosphocholines with Alzheimer's disease, O-sulfo-L-tyrosine with Parkinson's disease, glycine, xanthine with waist-to-hip ratio and ergothioneine with inflammatory bowel disease. Our study expanded the knowledge of MQTLs in the central nervous system, providing insights into human traits.

Age and Gender Disparities in the Association of Long-Term Dietary Choline and Choline Compound Intakes with Incident Cognitive Decline in Middle-Aged and Older Chinese Adults: A Prospective Cohort Study

Background/Objectives: The neuroprotective role of dietary choline during adulthood has not yet been conclusively proven. This study aims to investigate the influence of long-term choline and its constituent intakes on cognitive decline in the Chinese population. Methods: A total of 4502 subjects (≥55 years) with at least two waves of completed data and without cognitive decline at baseline were selected from the China Health and Nutrition Survey 1997-2018. Three consecutive 24 h dietary recalls were performed to collect dietary intake information for choline, phosphatidylcholine (PC), and glycerophosphocholine (GPC) measures. Several items from the Telephone Interview for Cognitive Status (Modified) were employed to perform a cognitive assessment. Cox frailty models were used to estimate hazard ratios (HRs) and 95% CIs. Results: A total of 783 participants developed cognitive decline during 26,080 person-years of follow-up. Cumulative average intakes of choline, PC, and GPC were 188.0, 126.7, and 17.1 mg/d, respectively. In the total population, after full adjustment, subjects in the lower (Q2), medium (Q3), higher (Q4), and highest (Q5) quintiles of dietary choline showed 27.8% (95% CI: 0.584, 0.894), 33.9% (95% CI: 0.522, 0.836), 23.0% (95% CI: 0.599, 0.990), and 29.3% (95% CI: 0.526, 0.949) decreases in the risk of cognitive decline compared to the lowest (Q1), respectively. Similar results were observed in PC but not GPC measures. Both higher choline and PC intakes induced a lower risk of cognitive decline for subjects ≥ 65 years at baseline (Q3 and Q4) and females (Q2-Q5). A marginally significant association of GPC was found for subjects ≥ 65 years (Q5) and males (Q4). Conclusions: These findings identify age and gender disparities relating to the protective associations of dietary choline, PC, and GPC with incident cognitive decline in middle-aged and older Chinese populations.

Effect of choline alfoscerate in older adult patients with dementia: an observational study from the claims data of national health insurance

BACKGROUND

Choline alfoscerate, a cholinergic precursor with limited evidence of efficacy in dementia management, has been used for various cognitive impairments in Korea. Partly due to its insurance coverage, this agent appears to incur significant expense for the insurance system. Thus, we aimed to describe choline alfoscerate prescription patterns and analyze their long-term effects in an older adult cohort with dementia.

METHODS

This observational study used the National Health Insurance Service Senior Cohort Dataset. Choline alfoscerate -naïve patients who were diagnosed with dementia between 2003 and 2014 with at least 12 months of follow-up were selected. Time-dependent Cox regression was employed to estimate the association between drug exposure and the risk of treatment failure events.

RESULTS

There were 11,463 eligible participants, of whom approximately 73% were female, and 19% had been exposed to choline alfoscerate. According to the main regression survival analysis, the association between longitudinal choline alfoscerate use and the risk of progression events related to treatment failure was unclear. However, a significant decrease of nearly 20% in the risk of all-cause mortality was associated with choline alfoscerate exposure, and a slight reduction in progression regarding treatment failure was observed with CA use only during the early stages of diagnosis. Age, sex, insurance premiums, several comorbidities and concurrent medications were significantly associated with the probability of the events according to the multivariate models.

CONCLUSIONS

Further analyses are needed to confirm the early-stage and long-term effectiveness of choline alfoscerate in specific populations, which will help in considering its reimbursement.

Role of Gpcpd1 in intestinal alpha-glycerophosphocholine metabolism and trimethylamine N-oxide production

Glycerophosphocholine (GPC) is an intracellular metabolite in phosphatidylcholine metabolism and has been studied for endogenous choline supply in cells. GPC, as a water-soluble supplement, has been expected to play a role in preventing brain disorders; however, recent studies have shown that intake of high levels of choline-containing compounds is related to trimethylamine N-oxide (TMAO) production in the liver, which is reportedly associated with the progression of atherosclerosis. In this study, we aimed to explore the mechanisms underlying the intestinal absorption and metabolism of GPC. Caco-2 cell monolayer experiments showed that exogenously added GPC was hydrolyzed to choline in the apical medium, and the resulting choline was transported into the Caco-2 cells and further to the basolateral medium. Subsequently, we focused on glycerophosphodiesterase 1 (Gpcpd1/GDE5), which hydrolyzes GPC to choline in vitro and is widely expressed in the gastrointestinal epithelium. Our results revealed that the Gpcpd1 protein was located not only in cells but also in the medium in which Caco-2 cells were cultured. Gpcpd1 siRNA decreased the GPC-hydrolyzing activity both inside Caco-2 cells and in conditioned medium, suggesting the involvement of Gpcpd1 in luminal GPC metabolism. Finally, we generated intestinal epithelial-specific Gpcpd1-deficient mice and found that Gpcpd1 deletion in intestinal epithelial cells affected GPC metabolism in intestinal tissues and partially abolished the increase in blood TMAO levels induced by GPC administration. These observations demonstrate that Gpcpd1 triggers choline production from GPC in the intestinal lumen and is a key endogenous enzyme that regulates TMAO levels following GPC supplementation.

Exerkine irisin mitigates cognitive impairment by suppressing gut-brain axis-mediated inflammation

INTRODUCTION

Exercise has been recognized to improve cognitive performance by optimizing gut flora and up-regulating exerkine irisin.

OBJECTIVE

Although exercise-induced irisin is beneficial to cognitive improvement, whether this benefit is achieved by optimizing gut microbiota and metabolites is not fully explored.

METHODS

After aerobic exercise and exogenous irisin interventions for 12 weeks, the 16S rRNA and metabolites in feces of 21-month-old mice were analyzed. Meanwhile, the differential miRNAs and mRNAs in hippocampal tissues were screened by high-throughput sequencing. Relevant mRNAs and proteins were evaluated by RT-PCR, Western blot, and immunofluorescence.

RESULTS

Compared with the young control mice, irisin levels and cognitive capacity of aged mice revealed a significant reduction, while aerobic exercise and intraperitoneal injection of exogenous irisin reversed aging-induced cognitive impairment. Similarly, 147 up-regulated and 173 down-regulated metabolites were detected in aged mice, while 64 and 45 up-regulated and 225 and 187 down-regulated metabolites were detected in aged mice with exercise and irisin interventions, respectively. Moreover, during hippocampal miRNA and mRNA sequencing analysis, 9 differential gut flora and 35 differential genes were identified to be correlated with the inflammatory signaling mediated by the TLR4/MyD88 signal pathway.

CONCLUSION

Aging-induced cognitive impairment is due to insulin resistance induced by TLR4/MyD88 signaling activation in hippocampal tissues mediated by gut microbiota and metabolite changes. Myokine irisin may be an important mediator in optimizing gut microbiota and metabolism for an improved understanding of mitigated aging process upon exercise interventions.

Effect of Choline Alfoscerate on the Progression From Mild Cognitive Impairment to Dementia: Distributed Network Analysis of a Multicenter Korean Database Using a Common Data Model

Background and Purpose

Choline alfoscerate (CA) is an acetylcholine precursor known for its beneficial effect on cognition in patient with Alzheimer's disease dementia (ADD). However, there is little evidence of its effects in patients with mild cognitive impairment (MCI). We assessed the influence of CA on the progression from MCI to all-cause dementia or ADD in three observational Korean databases using a Common Data Model (CDM).

Methods

Patients who were diagnosed with MCI and were aged over 60 years were included. After propensity score matching, 3,062 matched pairs patients using CA use and those not using CA were included. The Cox regression model was used to analyze the hazard ratio (HR) of CA use for conversion from MCI to all-cause dementia or ADD. Subgroup analyses were performed based on sex, acetylcholine esterase inhibitor (AchEI) use, and donepezil use.

Results

A meta-analysis across three hospitals revealed that CA use was not associated with the progression from MCI to all-cause dementia (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.59-1.26) or ADD (HR, 1.05; 95% CI, 0.51-1.59). Subgroup analyses revealed that CA use was not related to progression to all-cause dementia or ADD when stratified by sex, AchEI use, and donepezil use.

Conclusions

In this multicenter cohort study based on the Observational Medical Outcomes Partnership CDM real-world data, no association was noted between CA use and disease progression from MCI to all-cause dementia or ADD.

Trends and determinants of choline alfoscerate use in newly diagnosed Alzheimer's disease patients in Korea

BACKGROUND

Choline alfoscerate, a cholinergic precursor, is widely used in Korea for dementia-related symptoms and is covered by national health insurance (NHI). This study investigates the utilization trends and factors influencing choline alfoscerate prescription in newly diagnosed Alzheimer's disease (AD) patients using real-world data.

METHODS

We analyzed data from the Health Insurance Review and Assessment Service (HIRA) for patients aged 60 years and older who were newly diagnosed with AD between 2012 and 2019. Patients with prescriptions for acetylcholinesterase inhibitors (AChEIs) or memantine within 60 days of diagnosis were included. Choline alfoscerate utilization was defined as prescriptions within 60 days of initial diagnosis. Factors influencing its use were identified through multiple logistic regression analyses, and trends over time were assessed using the Cochran-Armitage Trend test.

RESULTS

Among the 330,326 study participants, 99,845 (33.08%) were prescribed choline alfoscerate, with usage increasing from 15.96% in 2012 to 47.65% in 2019. Factors positively associated with its use included male sex, MedAid insurance, and osteoarthritis. Conversely, usage decreased with comorbidities such as hypertension, congestive heart failure, stroke/transient ischemic attack, chronic kidney disease, and depression.

CONCLUSION

Choline alfoscerate usage in Korea has significantly increased, partly due to its national insurance coverage and the absence of disease-modifying therapies for AD. Given the uncertain efficacy and potential risks of choline alfoscerate, continuous monitoring and rigorous evaluation of its long-term benefits and safety are essential. Further research is necessary to establish definitive evidence for its effectiveness and guide its therapeutic use in AD management.

Highlights

Choline alfoscerate usage among newly diagnosed AD patients in Korea increased from 15.96% in 2012 to 47.65% in 2019.Male sex (OR = 1.05) and MedAid insurance coverage (OR = 1.07) were associated with higher odds of choline alfoscerate usage.Usage was more likely in patients with osteoarthritis (OR = 1.05) and less likely among those with hypertension (OR = 0.96), stroke/TIA (OR = 0.80), chronic kidney disease (OR = 0.80), and depression (OR = 0.93).Patients in rural areas had higher odds of using choline alfoscerate (OR = 1.28) compared to those in metropolitan areas (OR = 1.00).Despite limited evidence of efficacy, the extensive use of choline alfoscerate highlights the need for continuous monitoring and rigorous evaluation to ensure its safety and therapeutic value in AD management.

Efficacy and safety of choline alphoscerate for amnestic mild cognitive impairment: a randomized double-blind placebo-controlled trial

BACKGROUND

Effective interventions for overall healthy subjects with mild cognitive impairment are currently limited. Choline alphoscerate (alpha glyceryl phosphorylcholine, αGPC) is a choline-containing phospholipid used to treat cognitive function impairments in specific neurological conditions. This study aimed to investigate the efficacy and safety of αGPC in individuals diagnosed with mild cognitive impairment.

METHODS

In this multicenter, randomized, placebo-controlled trial, 100 study subjects with mild cognitive impairment underwent a double-blind SHCog™ soft capsule (600 mg αGPC) or placebo treatment for 12 weeks. The primary efficacy outcome included changes from baseline on the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog). Safety assessments included regular monitoring of adverse events, and clinical laboratory tests were conducted at baseline and the end of the trial.

RESULTS

After 12 weeks of αGPC treatment, the ADAS-cog score decreased by 2.34 points, which was significantly greater than the change observed in the placebo group. No serious AEs were reported, and no study subjects discontinued the intervention because of AEs. There was no significant difference in incidence rate of AEs between the αGPC group and the placebo group.

CONCLUSION

This study suggests that αGPC is a safe and effective intervention for improving cognitive function in study subjects with mild cognitive impairment.

TRIAL REGISTRATION

Clinical Research Information Service; Osong (Chungcheongbuk-do): Korea Centers for Disease Control and Prevention, Ministry of Health and Welfare (Republic of Korea); KCT0008797; A 12-week, multicenter, randomized, double-blind, placebo-controlled human application study to evaluate the efficacy and safety of SH_CAPK08 on cognitive function improvement in mild cognitive decline.

Effect of Treatment of the Cholinergic Precursor Choline Alphoscerate in Mild Cognitive Dysfunction: A Randomized Controlled Trial

Background and Objectives: The focus on mild cognitive dysfunction in adults is of great interest, given the risk of worsening and conversion to dementia. Cognitive dysfunctions are characterized by a decrease in the weight and volume of the brain, due to cortical atrophy, with a widening of the grooves and flattening of the convolutions. Brain atrophy that mainly involves the hippocampus is related to the progression of cognitive impairment and the conversion from mild cognitive dysfunction to dementia. Currently, there is no treatment for MCI. Results from a trial on Alzheimer's disease (ASCOMALVA trial) suggest that a sustained cholinergic challenge can slow the progression of brain atrophy typical of Alzheimer's disease associated with vascular damage. This study intends to evaluate the efficacy of choline alphoscerate in patients with mild cognitive impairment (MCI) and associated vascular damage, in stabilizing and/or slowing brain atrophy typical of adult-onset cognitive dysfunction, and in improving and/or slowing the progression of cognitive and behavioral symptoms associated with MCI. Materials and Methods: This randomized controlled trial will recruit 60 patients that will be evaluated and randomized in a 1:1 ratio to receive choline alphoscerate (1200 mg/day) or placebo, for 12 months. Analyses will be carried out using SPSS vesion No 26 the Statistician in charge of this study, with the statistical significance level chosen as 0.05. Discussion: This trial may provide evidence about the efficacy of treatment with the cholinergic precursor choline alphoscerate in patients with mild cognitive dysfunction. The results of this study will be published in peer-reviewed journals. Registration: EudraCT number: 2020-000576-38.

Pharmacological enhancement of cholinergic neurotransmission alleviates neuroinflammation and improves functional outcomes in a triple transgenic mouse model of Alzheimer's disease

Introduction: Alzheimer's disease (AD) is the most common neurodegenerative disorder affecting the elderly population worldwide. Due to the multifactorial nature of the disease, involving impairment of cholinergic neurotransmission and immune system, previous attempts to find effective treatments have faced challenges. Methods: In such scenario, we attempted to investigate the effects of alpha-glyceryl-phosphoryl-choline (α-GPC), a cholinomimetic molecule, on neuroinflammation and memory outcome in the triple transgenic mouse model of AD (3xTg-AD). Mice were enrolled at 4 months of age, treated orally with α-GPC dissolved in drinking water at a concentration resulting in an average daily dose of 100 mg/kg for 8 months and sacrificed at 12 months of age. Thereafter, inflammatory markers, as well as cognitive parameters, were measured. Results: Chronic α-GPC treatment reduced accumulation of amyloid deposits and led to a substantial re-balance of the inflammatory response of resident innate immune cells, astrocytes and microglia. Specifically, fluorescent immunohistochemistry and Western blot analysis showed that α-GPC contributed to reduction of cortical and hippocampal reactive astrocytes and pro-inflammatory microglia, concurrently increasing the expression of anti-inflammatory molecules. Whereas α-GPC beneficially affect the synaptic marker synaptophysin in the hippocampus. Furthermore, we observed that α-GPC was effective in restoring cognitive dysfunction, as measured by the Novel Object Recognition test, wherein 3xTg-AD mice treated with α-GPC significantly spent more time exploring the novel object compared to 3xTg-AD untreated mice. Discussion: In conclusion, chronic treatment with α-GPC exhibited a significant anti-inflammatory activity and sustained the key function of hippocampal synapses, crucial for the maintenance of a regular cognitive status. In light of our results, we suggest that α-GPC could be exploited as a promising therapeutic approach in early phases of AD.

Taming Microglia in Alzheimer's Disease: Exploring Potential Implications of Choline Alphoscerate via α7 nAChR Modulation

Alzheimer's disease (AD), marked by cognitive impairment, predominantly affects the brain regions regulated by cholinergic innervation, such as the cerebral cortex and hippocampus. Cholinergic dysfunction, a key contributor to age-related cognitive decline, has spurred investigations into potential therapeutic interventions. We have previously shown that choline alphoscerate (α-GPC), a cholinergic neurotransmission-enhancing agent, protects from Aβ-mediated neurotoxicity. Herein, we investigated the effects of α-GPC on the microglial phenotype in response to Aβ via modulation of the nicotinic alpha-7 acetylcholine receptor (α7 nAChR). BV2 microglial cells were pre-treated for 1 h with α-GPC and were treated for 24, 48, and 72 h with Aβ1-42 and/or α-BTX, a selective α7nAchR antagonist. Fluorescent immunocytochemistry and Western blot analysis showed that α-GPC was able to antagonize Aβ-induced inflammatory effects. Of note, α-GPC exerted its anti-inflammatory effect by directly activating the α7nAChR receptor, as suggested by the induction of an increase in [Ca2+]i and Ach-like currents. Considering that cholinergic transmission appears crucial in regulating the inflammatory profiles of glial cells, its modulation emerges as a potential pharmaco-therapeutic target to improve outcomes in inflammatory neurodegenerative disorders, such as AD.