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Lozupone M, Dibello V, Sardone R, Castellana F, Zupo R, Lampignano L, Bortone I, Stallone R, Altamura M, Bellomo A, Daniele A, Solfrizzi V, Panza F. Lessons learned from the failure of solanezumab as a prospective treatment strategy for Alzheimer's disease. Expert Opin Drug Discov 2024:1-9. [PMID: 38685682 DOI: 10.1080/17460441.2024.2348142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION In the last decade, the efforts conducted for discovering Alzheimer's Disease (AD) treatments targeting the best-known pathogenic factors [amyloid-β (Aβ), tau protein, and neuroinflammation] were mostly unsuccessful. Given that a systemic failure of Aβ clearance was supposed to primarily contribute to AD development and progression, disease-modifying therapies with anti-Aβ monoclonal antibodies (e.g. solanezumab, bapineuzumab, gantenerumab, aducanumab, lecanemab and donanemab) are ongoing in randomized clinical trials (RCTs) with contrasting results. AREAS COVERED The present Drug Discovery Case History analyzes the failures of RCTs of solanezumab on AD. Furthermore, the authors review the pharmacokinetics, pharmacodynamics, and tolerability effect of solanezumab from preclinical studies with its analogous m266 in mice. Finally, they describe the RCTs with cognitive, cerebrospinal fluid and neuroimaging findings in mild-to-moderate AD (EXPEDITION studies) and in secondary prevention studies (A4 and DIAN-TU). EXPERT OPINION Solanezumab was one of the first anti-Aβ monoclonal antibodies to be tested in preclinical and clinical AD showing to reduce brain Aβ level by acting on soluble monomeric form of Aβ peptide without significant results on deposits. Unfortunately, this compound showed to accelerate cognitive decline in both asymptomatic and symptomatic trial participants, and this failure of solanezumab further questioned the Aβ cascade hypothesis of AD.
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Affiliation(s)
- Madia Lozupone
- Department of Translational Biomedicine and Neuroscience "DiBraiN", University of Bari Aldo Moro, Bari, Italy
| | - Vittorio Dibello
- Dipartimento Interdisciplinare di Medicina, Clinica Medica e Geriatria "Cesare Frugoni", University of Bari Aldo Moro, Bari, Italy
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Rodolfo Sardone
- Unit of Statistics and Epidemiology, Local Health Authority of Taranto, Taranto, Italy
| | - Fabio Castellana
- Dipartimento Interdisciplinare di Medicina, Clinica Medica e Geriatria "Cesare Frugoni", University of Bari Aldo Moro, Bari, Italy
| | - Roberta Zupo
- Dipartimento Interdisciplinare di Medicina, Clinica Medica e Geriatria "Cesare Frugoni", University of Bari Aldo Moro, Bari, Italy
| | | | - Ilaria Bortone
- Local Healthcare Authority of Bari, ASL Bari, Bari, Italy
| | - Roberta Stallone
- Neuroscience and Education, Human Resources Excellence in Research, University of Foggia, Foggia, Italy
| | - Mario Altamura
- Psychiatric Unit, Department of Clinical & Experimental Medicine, University of Foggia, Foggia, Italy
| | - Antonello Bellomo
- Psychiatric Unit, Department of Clinical & Experimental Medicine, University of Foggia, Foggia, Italy
| | - Antonio Daniele
- Department of Neuroscience, Catholic University of Sacred Heart, Rome, Italy
- Neurology Unit, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Vincenzo Solfrizzi
- Dipartimento Interdisciplinare di Medicina, Clinica Medica e Geriatria "Cesare Frugoni", University of Bari Aldo Moro, Bari, Italy
| | - Francesco Panza
- Dipartimento Interdisciplinare di Medicina, Clinica Medica e Geriatria "Cesare Frugoni", University of Bari Aldo Moro, Bari, Italy
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Wang G, Li Y, Xiong C, Benzinger TLS, Gordon BA, Hassenstab J, Aschenbrenner AJ, McDade E, Clifford DB, Libre‐Guerra JJ, Shi X, Mummery CJ, van Dyck CH, Lah JJ, Honig LS, Day G, Ringman JM, Brooks WS, Fox NC, Suzuki K, Levin J, Jucker M, Delmar P, Bittner T, Bateman RJ. Examining amyloid reduction as a surrogate endpoint through latent class analysis using clinical trial data for dominantly inherited Alzheimer's disease. Alzheimers Dement 2024; 20:2698-2706. [PMID: 38400532 PMCID: PMC11032558 DOI: 10.1002/alz.13735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/18/2023] [Accepted: 01/18/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Increasing evidence suggests that amyloid reduction could serve as a plausible surrogate endpoint for clinical and cognitive efficacy. The double-blind phase 3 DIAN-TU-001 trial tested clinical and cognitive declines with increasing doses of solanezumab or gantenerumab. METHODS We used latent class (LC) analysis on data from the Dominantly Inherited Alzheimer Network Trials Unit 001 trial to test amyloid positron emission tomography (PET) reduction as a potential surrogate biomarker. RESULTS LC analysis categorized participants into three classes: amyloid no change, amyloid reduction, and amyloid growth, based on longitudinal amyloid Pittsburgh compound B PET standardized uptake value ratio data. The amyloid-no-change class was at an earlier disease stage for amyloid amounts and dementia. Despite similar baseline characteristics, the amyloid-reduction class exhibited reductions in the annual decline rates compared to the amyloid-growth class across multiple biomarker, clinical, and cognitive outcomes. DISCUSSION LC analysis indicates that amyloid reduction is associated with improved clinical outcomes and supports its use as a surrogate biomarker in clinical trials. HIGHLIGHTS We used latent class (LC) analysis to test amyloid reduction as a surrogate biomarker. Despite similar baseline characteristics, the amyloid-reduction class exhibited remarkably better outcomes compared to the amyloid-growth class across multiple measures. LC analysis proves valuable in testing amyloid reduction as a surrogate biomarker in clinical trials lacking significant treatment effects.
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Affiliation(s)
- Guoqiao Wang
- Washington University, School of MedicineSt. LouisMissouriUSA
| | - Yan Li
- Washington University, School of MedicineSt. LouisMissouriUSA
| | - Chengjie Xiong
- Washington University, School of MedicineSt. LouisMissouriUSA
| | | | - Brian A. Gordon
- Washington University, School of MedicineSt. LouisMissouriUSA
| | | | | | - Eric McDade
- Washington University, School of MedicineSt. LouisMissouriUSA
| | | | | | - Xinyu Shi
- Washington University, School of MedicineSt. LouisMissouriUSA
| | | | | | - James J. Lah
- Emory University Medical CenterAtlantaGeorgiaUSA
| | | | - Gregg Day
- Mayo Clinic JacksonvilleJacksonvilleFloridaUSA
| | - John M. Ringman
- Department of NeurologyKeck School of Medicine of USCLos AngelesCaliforniaUSA
| | - William S. Brooks
- Neuroscience Research Australia, Randwick NSW Australia, and School of Clinical MedicineUniversity of New South WalesRandwickNew South WalesAustralia
| | - Nick C. Fox
- Dementia Research CentreUniversity College LondonLondonUK
| | | | - Johannes Levin
- Department of NeurologyLudwig‐Maximilians‐Universität MünchenMunichGermany
- German Center for Neurodegenerative DiseasesMunichGermany
- Munich Cluster for Systems Neurology (SyNergy)MunichGermany
| | - Mathias Jucker
- Department of Cellular NeurologyHertie Institute for Clinical Brain ResearchUniversity of TübingenTübingenGermany
- German Center for Neurodegenerative Diseases (DZNE)TübingenGermany
| | | | - Tobias Bittner
- F.Hoffmann‐LaRoche, Ltd.BaselSwitzerland
- Genentech, Inc., a member of the Roche GroupSouth San FranciscoCaliforniaUSA
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Doggrell SA. More failure with solanezumab - this time in preclinical Alzheimer's disease. Expert Opin Biol Ther 2024. [PMID: 38414336 DOI: 10.1080/14712598.2024.2325551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/27/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION There is no cure for Alzheimer's disease, which is the sixth leading cause of death in the U.S.A.. Lecanemab is anti-Aβ monoclonal antibody approved for the treatment of early Alzheimer's disease but is only marginally effective. Other antibodies are being developed including solanezumab. AREAS COVERED A phase 3 clinical trial of solanezumab in preclinical Alzheimer's disease. In the A4 study, solanezumab did not reduce the decline in cognition or function and had no effect on brain amyloid burden. EXPERT OPINION After the poor results in the EXPEDITION series of trials, the development of solanezumab should have been terminated. The rationale for undertaking the A4 trial was questionable, and the lack of benefit was probable. The controversial approval of two anti-Aβ monoclonal antibodies (aducanumab, lecanemab) for the treatment of Alzheimer's disease by the US Food and Drug Administration (FDA), despite a high incidence of amyloid-related imagining abnormalities (ARIA), may be fueling this continuation of clinical development of agents such as solanezumab. The lesson from the A4 trial is that more careful/realistic consideration needs to be given before embarking on further phase 3 trials with anti-Aβ monoclonal antibodies.
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Affiliation(s)
- Sheila A Doggrell
- School of Pharmacy and Medical Sciences, Gold Coast Campus, Griffith University, Queensland, Australia
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Holdridge KC, Yaari R, Hoban DB, Andersen S, Sims JR. Targeting amyloid β in Alzheimer's disease: Meta-analysis of low-dose solanezumab in Alzheimer's disease with mild dementia studies. Alzheimers Dement 2023; 19:4619-4628. [PMID: 36946603 DOI: 10.1002/alz.13031] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/08/2023] [Accepted: 02/12/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Solanezumab is a monoclonal antibody that binds to the mid-domain of soluble amyloid β peptide. This meta-analysis evaluated the effect of low-dose solanezumab on clinical progression in three phase 3 studies. METHODS The population comprised patients aged ≥55 years with Alzheimer's disease (AD) with mild dementia, randomized to 400 mg solanezumab or placebo every 4 weeks for 80 weeks. Frequentist mixed-model repeated-measures (MMRM) and Bayesian disease progression model (DPM) longitudinal analyses were conducted. RESULTS Pooled MMRM analyses showed a statistically significant effect of solanezumab across cognitive and functional outcome measures. DPM results were generally consistent with MMRM results, ranging from 15% to 30% slowing of clinical progression. DISCUSSION These analyses suggest low-dose solanezumab slows clinical progression of AD with mild dementia. The ongoing A4 solanezumab study in participants with preclinical AD will ascertain the effect of a higher dose of solanezumab in an earlier disease stage. HIGHLIGHTS Individual EXPEDITION studies were negative but suggest low-dose solanezumab had an effect in slowing the clinical progression of Alzheimer's disease (AD) with mild dementia. At 80 weeks, mixed-model repeated-measures analyses showed numeric reductions in measures of clinical decline in solanezumab-treated arms compared with placebo across almost every outcome measure, and statistical significance in multiple outcome measures in each study. Pooled analyses suggest a high probability that low-dose solanezumab has at least some effect on slowing the clinical progression of AD with mild dementia. Across cognitive and functional outcome measures, estimates from disease progression model analyses range from 15% to 30% slowing of decline with low-dose solanezumab in AD with mild dementia.
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Affiliation(s)
| | - Roy Yaari
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | - John R Sims
- Eli Lilly and Company, Indianapolis, Indiana, USA
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Lozupone M, Berardino G, Mollica A, Sardone R, Dibello V, Zupo R, Lampignano L, Castellana F, Bortone I, Stallone R, Daniele A, Altamura M, Bellomo A, Solfrizzi V, Panza F. ALZT-OP1: An experimental combination regimen for the treatment of Alzheimer's Disease. Expert Opin Investig Drugs 2022; 31:759-771. [PMID: 35758153 DOI: 10.1080/13543784.2022.2095261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION For Alzheimer's disease (AD) treatment, US FDA granted accelerated approval for aducanumab due to its amyloid-β (Aβ)-lowering effects, notwithstanding the reported poor correlation between amyloid plaque reduction and clinical change for this drug. The diversification of drug targets appears to be the future of the AD field and from this perspective, drugs modulating microglia dysfunction and combination treatment regimens offer some promise. AREAS COVERED The aim of the present article was to provide a comprehensive review of ALZT-OP1 (cromolyn sodium plus ibuprofen), an experimental combination treatment regimen for AD, discussing their mechanisms of action targeting Aβ and neuroinflammation, examining the role of microglia in AD and offering our own insights on the role of present and alternative approaches directed toward neuroinflammation. EXPERT OPINION Enrolling high-risk participants with elevated brain amyloid could help to slow cognitive decline in secondary prevention trials during AD preclinical stages. Long-term follow-up indicated that non-steroidal anti-inflammatory drugs use begun when the brain was still normal may benefit these patients, suggesting that the timing of therapy could be crucial. However, previous clinical failures and the present incomplete understanding of the Aβ pathophysiological role in AD put this novel experimental combination regimen at substantial risk of failure.
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Affiliation(s)
- Madia Lozupone
- Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Berardino
- Psychiatric Unit, Department of Clinical & Experimental Medicine, University of Foggia, Foggia
| | - Anita Mollica
- Psychiatric Unit, Department of Clinical & Experimental Medicine, University of Foggia, Foggia
| | - Rodolfo Sardone
- Unit of Research Methodology and Data Sciences for Population Health, National Institute of Gastroenterology and Research Hospital IRCCS "S. De Bellis" Castellana Grotte, Bari, Italy
| | - Vittorio Dibello
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roberta Zupo
- Unit of Research Methodology and Data Sciences for Population Health, National Institute of Gastroenterology and Research Hospital IRCCS "S. De Bellis" Castellana Grotte, Bari, Italy
| | - Luisa Lampignano
- Unit of Research Methodology and Data Sciences for Population Health, National Institute of Gastroenterology and Research Hospital IRCCS "S. De Bellis" Castellana Grotte, Bari, Italy
| | - Fabio Castellana
- Unit of Research Methodology and Data Sciences for Population Health, National Institute of Gastroenterology and Research Hospital IRCCS "S. De Bellis" Castellana Grotte, Bari, Italy
| | - Ilaria Bortone
- Unit of Research Methodology and Data Sciences for Population Health, National Institute of Gastroenterology and Research Hospital IRCCS "S. De Bellis" Castellana Grotte, Bari, Italy
| | - Roberta Stallone
- Neuroscience and Education, Human Resources Excellence in Research, University of Foggia, Foggia, Italy
| | - Antonio Daniele
- Department of Neuroscience, Catholic University of Sacred Heart, Rome, Italy.,Neurology Unit, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Mario Altamura
- Psychiatric Unit, Department of Clinical & Experimental Medicine, University of Foggia, Foggia
| | - Antonello Bellomo
- Psychiatric Unit, Department of Clinical & Experimental Medicine, University of Foggia, Foggia
| | - Vincenzo Solfrizzi
- "Cesare Frugoni" Internal and Geriatric Medicine and Memory Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Panza
- Unit of Research Methodology and Data Sciences for Population Health, National Institute of Gastroenterology and Research Hospital IRCCS "S. De Bellis" Castellana Grotte, Bari, Italy
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Wang G, Li Y, Xiong C, McDade E, Clifford DB, Mills SL, Santacruz AM, Aschenbrenner AJ, Hassenstab J, Benzinger TL, Gordon BA, Fagan AM, Coalier KA, Libre‐Guerra JJ, McCullough A, Joseph‐Mathurin N, Chen CD, Mummery C, Wendelberger BA, Gauthier S, Masellis M, Holdridge KC, Yaari R, Chatterjee S, Sims J, Delmar P, Kerchner GA, Bittner T, Hofmann C, Bateman RJ. Evaluation of dose-dependent treatment effects after mid-trial dose escalation in biomarker, clinical, and cognitive outcomes for gantenerumab or solanezumab in dominantly inherited Alzheimer's disease. Alzheimers Dement (Amst) 2022; 14:e12367. [PMID: 36348972 PMCID: PMC9632865 DOI: 10.1002/dad2.12367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/21/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022]
Abstract
Introduction While the Dominantly Inherited Alzheimer Network Trials Unit (DIAN-TU) was ongoing, external data suggested higher doses were needed to achieve targeted effects; therefore, doses of gantenerumab were increased 5-fold, and solanezumab was increased 4-fold. We evaluated to what extent mid-trial dose increases produced a dose-dependent treatment effect. Methods Using generalized linear mixed effects (LME) models, we estimated the annual low- and high-dose treatment effects in clinical, cognitive, and biomarker outcomes. Results Both gantenerumab and solanezumab demonstrated dose-dependent treatment effects (significant for gantenerumab, non-significant for solanezumab) in their respective target amyloid biomarkers (Pittsburgh compound B positron emission tomography standardized uptake value ratio and cerebrospinal fluid amyloid beta 42), with gantenerumab demonstrating additional treatment effects in some downstream biomarkers. No dose-dependent treatment effects were observed in clinical or cognitive outcomes. Conclusions Mid-trial dose escalation can be implemented as a remedy for an insufficient initial dose and can be more cost effective and less burdensome to participants than starting a new trial with higher doses, especially in rare diseases. Highlights We evaluated the dose-dependent treatment effect of two different amyloid-specific immunotherapies.Dose-dependent treatment effects were observed in some biomarkers.No dose-dependent treatment effects were observed in clinical/cognitive outcomes, potentially due to the fact that the modified study may not have been powered to detect such treatment effects in symptomatic subjects at a mild stage of disease exposed to high (or maximal) doses of medication for prolonged durations.
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Affiliation(s)
- Guoqiao Wang
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | - Yan Li
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | - Chengjie Xiong
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | - Eric McDade
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | - David B. Clifford
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | - Susan L. Mills
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | - Anna M. Santacruz
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | | | - Jason Hassenstab
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | | | - Brian A. Gordon
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | - Anne M. Fagan
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | - Kelley A. Coalier
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | | | - Austin McCullough
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | | | - Charles D. Chen
- Washington University St LouisSchool of MedicineSt. LouisMissouriUSA
| | | | | | - Serge Gauthier
- McGill University Centre for Studies on Aging in MontrealMontrealQuebecCanada
| | - Mario Masellis
- University of TorontoSunnybrook Health Sciences CentreTorontoOntarioCanada
| | | | - Roy Yaari
- Eli Lilly and CompanyIndianapolisIndianaUSA
| | | | - John Sims
- Eli Lilly and CompanyIndianapolisIndianaUSA
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Madrasi K, Das R, Mohmmadabdul H, Lin L, Hyman BT, Lauffenburger DA, Albers MW, Rissman RA, Burke JM, Apgar JF, Wille L, Gruenbaum L, Hua F. Systematic in silico analysis of clinically tested drugs for reducing amyloid-beta plaque accumulation in Alzheimer's disease. Alzheimers Dement 2021; 17:1487-1498. [PMID: 33938131 PMCID: PMC8478725 DOI: 10.1002/alz.12312] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/21/2021] [Accepted: 01/21/2021] [Indexed: 01/28/2023]
Abstract
Introduction Despite strong evidence linking amyloid beta (Aβ) to Alzheimer's disease, most clinical trials have shown no clinical efficacy for reasons that remain unclear. To understand why, we developed a quantitative systems pharmacology (QSP) model for seven therapeutics: aducanumab, crenezumab, solanezumab, bapineuzumab, elenbecestat, verubecestat, and semagacestat. Methods Ordinary differential equations were used to model the production, transport, and aggregation of Aβ; pharmacology of the drugs; and their impact on plaque. Results The calibrated model predicts that endogenous plaque turnover is slow, with an estimated half‐life of 2.75 years. This is likely why beta‐secretase inhibitors have a smaller effect on plaque reduction. Of the mechanisms tested, the model predicts binding to plaque and inducing antibody‐dependent cellular phagocytosis is the best approach for plaque reduction. Discussion A QSP model can provide novel insights to clinical results. Our model explains the results of clinical trials and provides guidance for future therapeutic development.
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Affiliation(s)
| | | | | | - Lin Lin
- Applied Biomath, Concord, Massachusetts, USA
| | - Bradley T Hyman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Douglas A Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Mark W Albers
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Robert A Rissman
- Department of Neurosciences, UCSD School of Medicine, La Jolla, California, USA
| | | | | | - Lucia Wille
- Applied Biomath, Concord, Massachusetts, USA
| | | | - Fei Hua
- Applied Biomath, Concord, Massachusetts, USA
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Lozupone M, Solfrizzi V, D'Urso F, Di Gioia I, Sardone R, Dibello V, Stallone R, Liguori A, Ciritella C, Daniele A, Bellomo A, Seripa D, Panza F. Anti-amyloid-β protein agents for the treatment of Alzheimer's disease: an update on emerging drugs. Expert Opin Emerg Drugs 2020; 25:319-335. [PMID: 32772738 DOI: 10.1080/14728214.2020.1808621] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Currently available Alzheimer's disease (AD) therapeutics are only symptomatic, targeting cholinergic and glutamatergic neurotransmissions. Several putative disease-modifying drugs in late-stage clinical development target amyloid-β (Aβ) peptide and tau protein, the principal neurophatological hallmarks of the disease. AREAS COVERED Phase III randomized clinical trials of anti-Aβ drugs for AD treatment were searched in US and EU clinical trial registries and principal biomedical databases until May 2020. EXPERT OPINION At present, compounds in Phase III clinical development for AD include four anti-Ab monoclonal antibodies (solanezumab, gantenerumab, aducanumab, BAN2401), the combination of cromolyn sodium and ibuprofen (ALZT-OP1), and two small molecules (levetiracetam, GV-971). These drugs are mainly being tested in subjects during early AD phases or at preclinical stage of familial AD or even in asymptomatic subjects at high risk of developing AD. The actual results support the hypothesis that elevated Aβ represents an early stage in the AD continuum and demonstrate the feasibility of enrolling these high-risk participants in secondary prevention trials to slow cognitive decline during the AD preclinical stages. However, a series of clinical failures may question further development of Aβ-targeting drugs and the findings from current ongoing Phase III trials will hopefully give light to this critical issue.
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Affiliation(s)
- Madia Lozupone
- Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro , Bari, Italy
| | - Vincenzo Solfrizzi
- "Cesare Frugoni" Internal and Geriatric Medicine and Memory Unit, University of Bari "Aldo Moro" , Bari, Italy
| | - Francesca D'Urso
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia , Foggia, Italy
| | - Ilaria Di Gioia
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia , Foggia, Italy
| | - Rodolfo Sardone
- Population Health Unit - "Salus in Apulia Study" - National Institute of Gastroenterology, "Saverio De Bellis", Research Hospital , Bari, Italy
| | - Vittorio Dibello
- Population Health Unit - "Salus in Apulia Study" - National Institute of Gastroenterology, "Saverio De Bellis", Research Hospital , Bari, Italy.,Department of Orofacial Pain and Dysfunction, Academic Centre of Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam , The Netherlands
| | - Roberta Stallone
- Population Health Unit - "Salus in Apulia Study" - National Institute of Gastroenterology, "Saverio De Bellis", Research Hospital , Bari, Italy
| | - Angelo Liguori
- Population Health Unit - "Salus in Apulia Study" - National Institute of Gastroenterology, "Saverio De Bellis", Research Hospital , Bari, Italy
| | - Chiara Ciritella
- Physical and Rehabilitation Medicine Department, University of Foggia , Foggia, Italy
| | - Antonio Daniele
- Institute of Neurology, Catholic University of Sacred Heart , Rome, Italy.,Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Antonello Bellomo
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia , Foggia, Italy
| | - Davide Seripa
- Geriatric Unit and Gerontology-Geriatrics Research Laboratory, Department of Medical Sciences, IRCCS Casa Sollievo Della Sofferenza , Foggia, Italy.,Hematology and Stem Cell Transplant Unit, Vito Fazzi Hospital, ASL Lecce , Lecce, Italy
| | - Francesco Panza
- Population Health Unit - "Salus in Apulia Study" - National Institute of Gastroenterology, "Saverio De Bellis", Research Hospital , Bari, Italy
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Abstract
INTRODUCTION The amyloid-beta (Aβ) cascade hypothesis is that reducing Aβ levels in the brain will be beneficial in the treatment of Alzheimer's disease. Solanezumab is a humanized analog of a murine antibody that selectively targets the central domain of the soluble form of Aβ. In the EXPEDITION 1 and 2 Phase 3 clinical trials, solanezumab was shown to be ineffective in subjects with mild-to-moderate Alzheimer's disease, and to have no effect on brain Aβ burden. Areas covered: This evaluation considers the secondary analysis of (EXPEDITION 1 and 2), which led to the EXPEDITION 3 trial of solanezumab in subjects with mild Alzheimer's disease, and the results of EXPEDITION 3. Expert opinion: The secondary analysis of EXPEDITION 1 and 2 was limited to mild Alzheimer's disease, and showed improvements on some scales, but not others. This analysis did not report data on Aβ burden. In my opinion, this was a questionable basis to undertake a further phase trial with solanezumab. The EXPEDITION 3 trial of solanezumab in subjects with mild Alzheimer's disease was terminated early for ineffectiveness. With hindsight, solanezumab should have been discontinued after EXPEDITION 1 and 2, especially as it had not been shown to reduce Aβ burden.
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Affiliation(s)
- Sheila A Doggrell
- a Faculty of Health , Queensland University of Technology , Brisbane , Australia
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10
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Hassan M, Shahzadi S, Seo SY, Alashwal H, Zaki N, Moustafa AA. Molecular Docking and Dynamic Simulation of AZD3293 and Solanezumab Effects Against BACE1 to Treat Alzheimer's Disease. Front Comput Neurosci 2018; 12:34. [PMID: 29910719 PMCID: PMC5992503 DOI: 10.3389/fncom.2018.00034] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 05/11/2018] [Indexed: 12/21/2022] Open
Abstract
The design of novel inhibitors to target BACE1 with reduced cytotoxicity effects is a promising approach to treat Alzheimer's disease (AD). Multiple clinical drugs and antibodies such as AZD3293 and Solanezumab are being tested to investigate their therapeutical potential against AD. The current study explores the binding pattern of AZD3293 and Solanezumab against their target proteins such as β-secretase (BACE1) and mid-region amyloid-beta (Aβ) (PDBIDs: 2ZHV & 4XXD), respectively using molecular docking and dynamic simulation (MD) approaches. The molecular docking results show that AZD3293 binds within the active region of BACE1 by forming hydrogen bonds against Asp32 and Lys107 with distances 2.95 and 2.68 Å, respectively. However, the heavy chain of Solanezumab interacts with Lys16 and Asp23 of amyloid beta having bond length 2.82, 2.78, and 3.00 Å, respectively. The dynamic cross correlations and normal mode analyses show that BACE1 depicted good residual correlated motions and fluctuations, as compared to Solanezumab. Using MD, the Root Mean Square Deviation and Fluctuation (RMSD/F) graphs show that AZD3293 residual fluctuations and RMSD value (0.2 nm) was much better compared to Solanezumab (0.7 nm). Moreover, the radius of gyration (Rg) results also depicts the significance of AZD3293 docked complex compared to Solanezumab through residual compactness. Our comparative results show that AZD3293 is a better therapeutic agent for treating AD than Solanezumab.
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Affiliation(s)
- Mubashir Hassan
- College of Natural Science, Department of Biological Sciences, Kongju National University, Gongju, South Korea
| | - Saba Shahzadi
- Institute of Molecular Science and Bioinformatics, Lahore, Pakistan.,Department of Bioinformatics, Virtual University Davis Road, Lahore, Pakistan
| | - Sung Y Seo
- College of Natural Science, Department of Biological Sciences, Kongju National University, Gongju, South Korea
| | - Hany Alashwal
- College of Information Technology, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Nazar Zaki
- College of Information Technology, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ahmed A Moustafa
- School of Social Sciences and Psychology, MARCS Institute for Brain and Behaviour, Western Sydney University, Sydney, NSW, Australia
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Roher AE, Maarouf CL, Kokjohn TA, Belden C, Serrano G, Sabbagh MS, Beach TG. Chemical and neuropathological analyses of an Alzheimer's disease patient treated with solanezumab. Am J Neurodegener Dis 2016; 5:158-170. [PMID: 27725918 PMCID: PMC5043095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Based on the amyloid cascade hypothesis of Alzheimer's disease (AD) pathogenesis, a series of clinical trials involving immunotherapies have been undertaken including infusion with the IgG1 monoclonal anti-Aβ antibody solanezumab directed against the middle of the soluble Aβ peptide. In this report, we give an account of the clinical history, psychometric testing, gross and microscopic neuropathology as well as immunochemical quantitation of soluble and insoluble Aβ peptides and other proteins of interest related to AD pathophysiology in a patient treated with solanezumab. MATERIALS AND METHODS The solanezumab-treated AD case (SOLA-AD) was compared to non-demented control (NDC, n = 5) and non-immunized AD (NI-AD, n = 5) subjects. Brain sections were stained with H&E, Thioflavine-S, Campbell-Switzer and Gallyas methods. ELISA and Western blots were used for quantification of proteins of interest. RESULTS The SOLA-AD subject's neuropathology and biochemistry differed sharply from the NDC and NI-AD groups. The SOLA-AD case had copious numbers of amyloid laden blood vessels in all areas of the cerebral cortex, from leptomeningeal perforating arteries to arteriolar deposits which attained the cerebral amyloid angiopathy (CAA) maximum score of 12. In contrast, the maximum CAA for the NI-AD cases averaged a total of 3.6, while the NDC cases only reached 0.75. The SOLA-AD subject had 4.4-fold more soluble Aβ40 and 5.6-fold more insoluble Aβ40 in the frontal lobe compared to NI-AD cases. In the temporal lobe of the SOLA-AD case, the soluble Aβ40 was 80-fold increased, and the insoluble Aβ40 was 13-fold more abundant compared to the non-immunized AD cases. Both soluble and insoluble Aβ42 levels were not dramatically different between the SOLA-AD and NI-AD cohort. DISCUSSION Solanezumab immunotherapy provided no apparent relief in the clinical evolution of dementia in this particular AD patient, since there was a continuous cognitive deterioration and full expression of amyloid deposition and neuropathology.
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Affiliation(s)
- Alex E Roher
- Division of Clinical Education, Midwestern UniversityGlendale, AZ 85308
- Division of Neurobiology, Barrow Neurological InstitutePhoenix, AZ 85013
| | - Chera L Maarouf
- Laboratory of Neuropathology, Banner Sun Health Research InstituteSun City, AZ 85351
| | - Tyler A Kokjohn
- Department of Microbiology, Midwestern UniversityGlendale, AZ 85308
| | - Christine Belden
- Cleo Roberts Center for Clinical Research, Banner Sun Health Research InstituteSun City, AZ 85351
| | - Geidy Serrano
- Laboratory of Neuropathology, Banner Sun Health Research InstituteSun City, AZ 85351
| | - Marwan S Sabbagh
- Alzheimer’s and Memory Disorders Division, Barrow Neurological InstitutePhoenix, AZ 85013
| | - Thomas G Beach
- Laboratory of Neuropathology, Banner Sun Health Research InstituteSun City, AZ 85351
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Liu-Seifert H, Siemers E, Price K, Han B, Selzler KJ, Henley D, Sundell K, Aisen P, Cummings J, Raskin J, Mohs R. Cognitive Impairment Precedes and Predicts Functional Impairment in Mild Alzheimer's Disease. J Alzheimers Dis 2016; 47:205-14. [PMID: 26402769 PMCID: PMC4923754 DOI: 10.3233/jad-142508] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: The temporal relationship of cognitive deficit and functional impairment in Alzheimer’s disease (AD) is not well characterized. Recent analyses suggest cognitive decline predicts subsequent functional decline throughout AD progression. Objective: To better understand the relationship between cognitive and functional decline in mild AD using autoregressive cross-lagged (ARCL) panel analyses in several clinical trials. Methods: Data included placebo patients with mild AD pooled from two multicenter, double-blind, Phase 3 solanezumab (EXPEDITION/2) or semagacestat (IDENTITY/2) studies, and from AD patients participating in the Alzheimer’s Disease Neuroimaging Initiative (ADNI). Cognitive and functional outcomes were assessed using AD Assessment Scale-Cognitive subscale (ADAS-Cog), AD Cooperative Study-Activities of Daily Living instrumental subscale (ADCS-iADL), or Functional Activities Questionnaire (FAQ), respectively. ARCL panel analyses evaluated relationships between cognitive and functional impairment over time. Results: In EXPEDITION, ARCL panel analyses demonstrated cognitive scores significantly predicted future functional impairment at 5 of 6 time points, while functional scores predicted subsequent cognitive scores in only 1 of 6 time points. Data from IDENTITY and ADNI programs yielded consistent results whereby cognition predicted subsequent function, but not vice-versa. Conclusions: Analyses from three databases indicated cognitive decline precedes and predicts subsequent functional decline in mild AD dementia, consistent with previously proposed hypotheses, and corroborate recent publications using similar methodologies. Cognitive impairment may be used as a predictor of future functional impairment in mild AD dementia and can be considered a critical target for prevention strategies to limit future functional decline in the dementia process.
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Affiliation(s)
- Hong Liu-Seifert
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Eric Siemers
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Karen Price
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Baoguang Han
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | | | - David Henley
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA.,Indiana University School of Medicine, Indianapolis, IN, USA
| | - Karen Sundell
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Paul Aisen
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | | | - Richard Mohs
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
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Liu-Seifert H, Siemers E, Sundell K, Price K, Han B, Selzler K, Aisen P, Cummings J, Raskin J, Mohs R. Cognitive and functional decline and their relationship in patients with mild Alzheimer's dementia. J Alzheimers Dis 2015; 43:949-55. [PMID: 25125457 DOI: 10.3233/jad-140792] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In patients with Alzheimer's disease (AD), the relationship between cognitive and functional progression is not fully understood; however, functional decline has been postulated to follow cognitive decline. OBJECTIVE To assess the relationship between cognitive and functional treatment effects in mild AD dementia patients. METHODS Data of patients with mild AD were pooled from two multicenter, double-blind, Phase 3 studies. Patients were randomized to infusions of 400-mg solanezumab (n = 654), or placebo (n = 660) every 4 weeks for 18 months. Cognitive and functional outcome measures were assessed using the AD Assessment Scale-Cognitive subscale (ADAS-Cog) and the AD Cooperative Study-Activities of Daily Living (ADCS-ADL), respectively. Analyses included comparisons among normalized scales, correlations between outcome measures, and path analyses to model the relationship of treatment effect on cognition and function. RESULTS Normalized ADAS-Cog and ADCS-ADL scales showed cognitive impairment was more evident than functional impairment in mild AD. The correlation between cognition and function increased over time. Path analyses demonstrated that 87% of the treatment effect on function was driven by the treatment effect on cognition, with the remaining 13% due to direct treatment effect. CONCLUSION Findings from this study are consistent with the hypothesis that functional impairment is primarily driven by and follows cognitive decline in mild AD dementia. The cognitive treatment effect appeared to explain the majority of the functional treatment effect. It is possible that a cognitive treatment effect may be considered as a leading indicator for functional outcomes in an 18-month clinical trial for milder stages of AD.
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Affiliation(s)
- Hong Liu-Seifert
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Eric Siemers
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Karen Sundell
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Karen Price
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Baoguang Han
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Katherine Selzler
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
| | - Paul Aisen
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | | | - Richard Mohs
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, USA
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Abstract
Trials missing primary efficacy end points raise the question of whether the choice of drug or the limitations of disease biology were at fault. In some trials, drugs appear not to have achieved biochemical effect thresholds sufficient for clinical benefit. This suggests the need for improved drugs that are more active at tolerated doses. In other trials, it is unclear how the observed biomarker changes are related to potential efficacy. However, hints of efficacy from exploratory analyses support the idea that starting treatment earlier in the course of the disease might be more effective. A closer look at the failed trials will help de-risk future trials.
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Affiliation(s)
- Jeremy Toyn
- Pharmaceutical and Biotechnology Consultant, P.O. Box 11, Belmont, MA 02478, USA
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Hampel H, Schneider LS, Giacobini E, Kivipelto M, Sindi S, Dubois B, Broich K, Nisticò R, Aisen PS, Lista S. Advances in the therapy of Alzheimer's disease: targeting amyloid beta and tau and perspectives for the future. Expert Rev Neurother 2014; 15:83-105. [PMID: 25537424 DOI: 10.1586/14737175.2015.995637] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Worldwide multidisciplinary translational research has led to a growing knowledge of the genetics and molecular pathogenesis of Alzheimer's disease (AD) indicating that pathophysiological brain alterations occur decades before clinical signs and symptoms of cognitive decline can be diagnosed. Consequently, therapeutic concepts and targets have been increasingly focused on early-stage illness before the onset of dementia; and distinct classes of compounds are now being tested in clinical trials. At present, there is a growing consensus that therapeutic progress in AD delaying disease progression would significantly decrease the expanding global burden. The evolving hypothesis- and evidence-based generation of new diagnostic research criteria for early-stage AD has positively impacted the development of clinical trial designs and the characterization of earlier and more specific target populations for trials in prodromal as well as in pre- and asymptomatic at-risk stages of AD.
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Panza F, Solfrizzi V, Imbimbo BP, Giannini M, Santamato A, Seripa D, Logroscino G. Efficacy and safety studies of gantenerumab in patients with Alzheimer's disease. Expert Rev Neurother 2014; 14:973-86. [PMID: 25081412 DOI: 10.1586/14737175.2014.945522] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Among active and passive anti-β-amyloid (Aβ) immunotherapies for Alzheimer's disease (AD), bapineuzumab and solanezumab, two humanized monoclonal antibodies, failed to show significant clinical benefits in mild-to-moderate AD patients in large Phase III clinical trials. Another ongoing Phase III trial of solanezumab aims to confirm positive findings in mild AD patients. Gantenerumab is the first fully human anti-Aβ monoclonal antibody directed to both N-terminal and central regions of Aβ. A 6-month PET study in 16 AD patients showed that gantenerumab treatment dose-dependently reduced brain Aβ deposition, possibly stimulating microglial-mediated phagocytosis. Two ongoing Phase III trials of gantenerumab in patients with prodromal or mild dementia due to AD will determine if any reduction in brain Aβ levels will translate into clinical benefits. An ongoing secondary prevention trial of gantenerumab in presymptomatic subjects with genetic mutations for autosomal-dominant AD will verify the utility of anti-Aβ monoclonal antibodies as prevention therapy.
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Affiliation(s)
- Francesco Panza
- Department of Basic Medicine, Neuroscience, and Sense Organs, Neurodegenerative Disease Unit, University of Bari Aldo Moro, Bari, Italy
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Panza F, Solfrizzi V, Imbimbo BP, Logroscino G. Amyloid-directed monoclonal antibodies for the treatment of Alzheimer's disease: the point of no return? Expert Opin Biol Ther 2014; 14:1465-76. [PMID: 24981190 DOI: 10.1517/14712598.2014.935332] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Two humanized monoclonal antibodies, bapineuzumab and solanezumab, directed against the N terminus and mid-region of β-amyloid (Aβ), respectively, were recently tested in large, long-term Phase III trials in patients with mild-to-moderate Alzheimer's disease (AD). AREAS COVERED This review discusses current clinical data on solanezumab, bapineuzumab and their failure in Phase III trials to show significant clinical benefits, as well as other monoclonal antibodies under investigation for AD. EXPERT OPINION Solanezumab showed some beneficial cognitive effects in mildly affected AD patients and this subgroup of AD patients is currently being tested in another Phase III trial to this subgroup of AD patients to confirm previous encouraging observations. Two other monoclonal antibodies, gantenerumab, which preferentially binds to fibrillar Aβ, and crenezumab, which preferentially binds to soluble, oligomeric and fibrillar Aβ deposits, are being tested in secondary prevention trials in presymptomatic subjects with autosomal dominant AD mutations. Solanezumab is also being tested in a prevention study in asymptomatic older subjects, who have positive positron emission tomography scans for brain amyloid deposits. These ongoing secondary prevention trials will tell us if Aβ really plays a crucial role in the pathophysiology of AD.
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Affiliation(s)
- Francesco Panza
- University of Bari Aldo Moro, Department of Basic Medicine, Neuroscience, and Sense Organs, Neurodegenerative Disease Unit , Bari , Italy
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