Alzheimer's disease research
As of April 2014 there were 315 open clinical trials under way to understand and treat Alzheimer's disease. 42 of these studies were open, human phase three trials, the last step before U.S. Food and Drug Administration approval and marketing.
There are different approaches. One approach is to reduce Amyloid beta, for example with bapineuzumab, an antibody in phase III studies for patients in mild to moderate stage; semagacestat, a γ-secretase inhibitor, MPC-7869; and acc-001 or CAD106, vaccines against amyloid beta. Other approaches are neuroprotective agents, like AL-108 (phase II completed); or metal-protein interaction attenuation, as is the case of PBT2 (phase II completed). Yet another approach is to use general cognitive enhancers, as may be the case for memantine, a pharmaceutical approved in the United States and European Union to treat moderate-to-severe AD. Finally, there are basic investigations on the origin and mechanisms of Alzheimer's disease.
- 1 Treatments in clinical development
- 1.1 Immunotherapy to amyloid beta
- 1.2 Metabolic correction
- 1.3 Other pharmaceuticals
- 2 Disease-modifying drug candidates
- 3 Non-Imaging biomarkers
- 4 References
Treatments in clinical development
Multiple potential treatments for Alzheimer's disease are currently under investigation, including several compounds being studied in phase 3 clinical trials. The most important clinical research is focused on potentially treating the underlying disease pathology, for which reduction of amyloid beta is a common target of compounds under investigation.
Immunotherapy to amyloid beta
Immunotherapy or vaccination for Alzheimer's stimulates the immune system to attack beta-amyloid. One approach is active immunization, which would stimulate a permanent immune response. The vaccine AN-1792 showed promise in mouse and early human trials, but in a 2002 Phase II trial, 6% of subjects (18 of 300) developed serious brain inflammation resembling meningoencephalitis, and the trial was stopped. In long-term followups, 20% of subjects had developed high levels of antibodies to beta-amyloid. While placebo-patients and non-antibody responders worsened, these antibody-responders showed a degree of stability in cognitive levels as assessed by the neuropsychological test battery (although not by other measures), and had lower levels of the protein tau in their cerebrospinal fluid. These results may suggest reduced disease activity in the antibody-responder group. Autopsies found that immunization resulted in clearance of amyloid plaques, but did not prevent progressive neurodegeneration.
A Phase IIA study of ACC-001, a modified version of AN-1792, is now recruiting subjects.
Also derived from the AN-1792 immunotherapy program, there is an infused antibody approach termed a passive vaccine in that it does not invoke the immune system and would require regular infusions to maintain the artificial antibody levels. Micro-cerebral hemorrhages may be a threat to this process.
The most advanced such candidate is known as bapineuzumab or aab-001, and this antibody is designed as essentially identical to the natural antibody triggered by the earlier AN-1792 vaccine. The aab-001 antibody is in Phase 3 clinical trials for both Apolipoprotein E4 gene carriers, and Apolipoprotein E4 gene non-carriers.
Gamma secretase inhibition
Gamma secretase modulation
Tarenflurbil (MPC-7869, formerly R-flubiprofen) is a gamma secretase modulator sometimes called a selective amyloid beta 42 lowering agent. It is believed to reduce the production of the toxic amyloid beta in favor of shorter forms of the peptide. Negative results were announced regarding tarenflurbil in July 2008 and further development was canceled.
Metal-protein interaction attenuation
PBT2 is an 8-hydroxy quinoline that removes copper and zinc from cerebrospinal fluid, which are held to be necessary catalysts for amyloid beta aggregation. This drug has been in a Phase II trial for early Alzheimers and which has reported preliminarily promising, but not detailed, results.
Simvastatin, a statin, stimulates brain vascular endothelial cells to create a beta-amyloid ejector. The use of this statin may have a causal relationship to decreased development of the disease.
This approach is based on the prominent aspect of Alzheimer's disease, which is common for many other neurodegenerative diseases: energy deficit. It has first been noted for the case of insulin insufficiency in the brain of Alzheimer's patients. Because of that Alzheimer's disease has been called "Type 3 diabetes"  and the insulin modification therapies are currently in pharmaceutical's pipelines.
Several other pharmaceuticals are under investigation to treat Alzheimer's disease.
Allopregnanolone has been identified as a potential drug agent. Levels of neurosteroids such as allopregnanolone decline in the brain in old age and AD. Allopregnanolone has been shown to aid the neurogenesis that reverses cognitive deficits in a mouse model of AD.
Angiotensin receptor blockers
A retrospective analysis of five million patient records with the US Department of Veterans Affairs system found that different types of commonly used anti-hypertensive medications had very different AD outcomes. Those patients taking angiotensin receptor blockers (ARBs) were 35—40% less likely to develop AD than those using other anti-hypertensives.
Only one clinical trial is being done (at McMaster University) to investigate the efficacy of antibiotic therapy. The authors of the study indicated that it was effective in delaying the progress of the disease: "In conclusion, a 3-month course of doxycycline and rifampin reduced cognitive worsening at 6 months of follow-up in patients with mild to moderate AD." A re-examination of the same data using: "...AUC analysis of the pooled index showed significant treatment effect over the 12-month period".
Several studies using minocycline and doxycycline, in an animal model of Alzheimer's Disease, have indicated that minocycline and doxycycline exerts a protective effect in preventing neuron death and slowing the onset of the disease.
The endocannabinoid system may have a role in AD. For instance, THC, one of the active ingredients in marijuana, has been show to reduce amyloid beta plaque formation through inhibition of acetylcholinesterase (AChE).
Also in July 2008 results were announced of a study in which an antihistamine that was formerly available in Russia, Dimebon, was given to a group of AD patients. The group receiving Dimebon improved somewhat over the 6 months of the study (and this continued for the next six months), whereas those on placebo deteriorated. Unfortunately the consecutive phase-III trial failed to show significant positive effects in the primary and secondary endpoints. The sponsors acknowledged in March 2010 that initial results of the phase III trial showed that while the drug had been well tolerated, its outcomes did not significantly differ from the placebo control.
A 2006 pilot study showed small but significant improvements in various cognitive rating scales in patients with Alzheimer's disease after treatment with etanercept, a Tumor necrosis factor-alpha receptor fusion protein, which binds to tumor necrosis factor-alpha, and decreases its role in inflammation of nervous tissue. Etanercept was administered by perispinal infusion to 15 AD patients which resulted in sustained improvement in cognitive function; however it is not clear if this was temporary or not. A small trial consisting of 50 patients has commenced. A 12 person replication study is being run by Griffith University, Australia. A study published in 2008 of etanercept, administered to a single AD patient via perispinal infusion, showed rapid (within 10 minutes) and significant improvement in Alzheimer's symptoms that lasted until the end of the study, which involved weekly injections.
Insulin sensitizers and Intranasal insulin
Recent studies suggest an association between insulin resistance and AD (fat cell sensitivity to insulin can decline with aging): In clinical trials, a certain insulin sensitizer called "rosiglitazone" improved cognition in a subset of AD patients; in vitro, beneficial effects of Rosiglitazone on primary cortical rat neurons have been demonstrated Initial research suggests intranasal insulin might also be utilized - increasing insulin levels in the brain with minimal insulin increase in the rest of the body :
CNS Drugs. 2013 Jul;27(7):505-14. doi: 10.1007/s40263-013-0076-8. Intranasal insulin as a treatment for Alzheimer's disease: a review of basic research and clinical evidence. Freiherr J1, Hallschmid M, Frey WH 2nd, Brünner YF, Chapman CD, Hölscher C, Craft S, De Felice FG, Benedict C. http://www.ncbi.nlm.nih.gov/pubmed/23719722
Recently, the FDA approved a an intranasal insulin device :
Afrezza, a New Inhaled Insulin, Is Approved by the F.D.A. http://www.nytimes.com/2014/06/28/business/afrezza-a-new-inhaled-insulin-is-approved-by-fda.html?ref=health
In July 2008, researchers announced positive results from methylthioninium chloride (MTC), (trade name: Rember) a drug that dissolved Tau polymers. Phase II results indicate that it is the first therapy that has success in modifying the course of disease in mild to moderate AD.
Originally considered an enigmatic protein, the sigma-1 receptor has been identified as a unique ligand-regulated molecular chaperone in the endoplasmic reticulum of cells. This discovery led to the review of many proposed roles of this receptor in many neurological diseases including Alzheimer's.
Disease-modifying drug candidates
|Target/Approach||Notes (Theoretical)||Candidate Name||Trial Phase||Trial Start Date||Expected End Date||Planned Enrollment||AD population targeted (severity)||AD population targeted (genetic)||Comments|
|Gamma Secretase Modulator/NSAID||Shifts amyloid beta production to shorter and less toxic species. Targets γ-secretase.||Flurizan (R-flurbiprofen, MPC-7869)||Phase III (completed)||Feb 2005||May 2008||1,600||Mild||n/a||Myriad Genetics concluded that the drug did not improve thinking ability or the ability of patients to carry out daily activities significantly more than those patients with placebo. Peter Meldrum, CEO of Myriad Genetics, announced on June 30, 2008 that the company will no longer be developing Flurizan|
|Gamma Secretase Inhibitor||Inhibits Gamma Secretase, which reduces amyloid beta levels||Semagacestat (LY450139)||Phase III (completed)||Sep 2008||Apr 2011||1,100||Mild-to-Moderate||n/a||On August 17, 2010, Eli Lilly announced that it "will halt development of semagacestat" as it "did not slow disease progression and was associated with worsening...cognition and the ability to perform activities of daily living." Also, it is "associated with an increased risk of skin cancer."|
|Antibody to amyloid beta||Mimics natural antibody triggered by AN-1792||Bapineuzumab (aab-001)||Phase III (completed)||Dec 2007||Apr 2012||1,121||Mild-to-Moderate||Apolipoprotein E4 Carriers only||On August 6, 2012, Pfizer and Johnson & Johnson said they are "ending development of an intravenous formulation" of bapineuzumab. Phase III trials "showed no treatment effect on either cognitive or functional outcomes. Biomarker analyses indicated that bapineuzumab engaged its target, but had no benefit."|
|Antibody to amyloid beta||Mimics natural antibody triggered by AN-1792||Bapineuzumab (aab-001)||Phase III (completed)||Dec 2007||Jun 2012||1,331||Mild-to-Moderate||Apolipoprotein E4 Non-Carriers only||On August 6, 2012, Pfizer and Johnson & Johnson said they are "ending development of an intravenous formulation" of bapineuzumab. Phase III trials "showed no treatment effect on either cognitive or functional outcomes. Biomarker analyses indicated that bapineuzumab engaged its target, but had no benefit."|
|Metal-Protein Interaction Attenuation||Primary targets are copper and zinc. Removes copper and zinc from cerebrospinal fluid.||PBT2 (8-hydroxy quinoline)||Phase II (completed)||Dec 2006||Dec 2007||80||Early Alzheimer's disease||n/a||"Did not meet its primary endpoint of a statistically significant reduction in the levels of beta-amyloid plaques in the brains prodromal/mild Alzheimer's disease patients." "No improvement was observed on the secondary endpoints of brain metabolic activity, cognition and function; however, there was a trend towards preserving hippocampal brain volume". "Specifically, there was less atrophy relative to the placebo group."|
|Fibrilization of amyloid beta||Breaks down neurotoxic fibrils, allowing amyloid peptides to clear the body rather than form amyloid plaques.||ELND005 (AZD-103, scyllo-Inositol)||Phase II (completed)||Dec 2007||May 2010||353||Mild-to-Moderate||n/a||Phase I produced encouraging results by August 2007. In December 2009, Elan and Transition jointly reported that the Phase II study has been modified so that only the 250 mg twice daily dose will be continued due to "greater rates of serious adverse events, including nine deaths," in the higher dose groups (1000 mg and 2000 mg dosed twice daily). It has received fast track designation from the U.S. FDA.|
|Neuroprotection||Neuroprotective Peptide, intra-nasal||AL-108||Phase II (completed)||Jan 2007||Jan 2008||120||Mild Cognitive Impairment||n/a||Deemed a Success; Phase III to start|
|Brain Cell Apoptosis Inhibitor||Operates through multiple mechanisms: Blocks the action of neurotoxic beta-amyloid proteins and inhibits L-type calcium channels, modulates the action of AMPA and NMDA glutamate receptors, may exert a neuroprotective effect by blocking a novel target that involves mitochondrial pores, and blocks a number of other receptors, including α-adrenergic, 5-HT2C, 5-HT5A, and 5-HT6||Dimebon (Latrepirdine)||Phase II (completed)||Sep 2006||Nov 2007 (actual)||183||Mild-to-Moderate||n/a||In March 2010, Pfizer announced that the Phase III CONNECTION trial failed to meet its primary and secondary endpoints. In January 2012, it was announced that the Phase III CONCERT study did not meet its co-primary endpoints. Both CONTACT and CONSTELLATION trials were terminated. Medivation and Pfizer discontinued development of dimebon and thus decided to end their co-development and marketing collaboration.|
|Natural Antibodies to amyloid beta||human plasma source limits supply||IVIg||Phase II (completed)||Feb 2006||June 2007||24||Mild-to-Moderate||n/a||Deemed a Success; Phase III to start|
|Vaccine to amyloid beta||Injects modified amyloid beta (active vaccine)||acc-001||Phase II||Nov 2007||Mar 2012||228||Mild-to-Moderate||n/a||Sequel to famous AN-1792 Vaccine Trial|
Recent studies have shown that people with AD had decreased glutamate (Glu) as well as decreased Glu/creatine (Cr), Glu/myo-inositol (mI), Glu/N-acetylaspartate (NAA), and NAA/Cr ratios compared to normal people. Both decreased NAA/Cr and decreased hippocampal glutamate may be an early indicator of AD.
Early research using a small cohort of Alzheimer's disease patients may have identified autoantibody markers for AD. The applicability of these markers is unknown.
A small human study in 2011 found that monitoring blood dehydroepiandrosterone (DHEA) variations in response to an oxidative stress could be a useful proxy test: the subjects with MCI did not have a DHEA variation, while the healthy controls did.
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