Alzheimers disease: what

is new in detection and

treatment
Dr. Doha Rasheedy Ali
Lecturer of Geriatric medicine
Ain Shams University

BACKGROUND

Histopathology of Alzheimer s
dementia
1. Neuronal degeneration
2. Intracellular deposits known as
neurofibrillary tangles (NFTs).
3. Extracellular deposits known as
senile plaques (SPs).

NFTs structure
Neurofibrillary tangle is composed of abnormal
fibrils measuring 10 nm in diameter that occur in
pairs and are wound in a helical fashion with a
regular periodicity of 80 nm.
The primary constituent of the neurofibrillary
tangle is the microtubule-associated protein
tau. The tau within neurofibrillary tangles is
abnormally phosphorylated.
There are a number of other protein constituents
associated with the neurofibrillary tangle, such as
ubiquitin, cholinesterases, and beta-amyloid

Distribution of NFTs
Severe involvement is seen in:
1. the layer II neurons of the entorhinal
cortex, the cornu ammonis 1 and subicular
regions of the hippocampus, the amygdala,
2. the deeper layers (layers III, V, and
superficial VI) of the neocortex.
The extent and distribution of neurofibrillary
tangles in cases of Alzheimer's disease
correlate with both the degree of dementia
and the duration of illness.

SPs structure
Extracellular polymorphous amyloid deposits
found in the brain most prominently in
Alzheimer disease but also in normal aging.
Their 6- to 10-nm-wide filaments consist of a 39to 42-amino acid -amyloid protein (-AP) which
is derived from proteolysis of transmembrane
amyloid precursor protein (APP)
A is a normal cellular product and is present in
nanomolar concentrations in biological fluids, at
higher concentrations, it is extremely insoluble
and precipitates to form aggregates

 The most characteristic form of the amyloid

plaque, is characterized by a dense core of
aggregated fibrillar A, surrounded by
dystrophic dendrites and axons, activated
microglia, and reactive astrocytes.
The diffuse plaques: diffuse deposits of A,
likely representing a prefibrillary form of
the aggregated peptide, are found without
any surrounding dystrophic neurites,
astrocytes, or microglia. These diffuse
plaques can be found in limbic and
association cortices, as well as in the
cerebellum.

Vascular Amyloid Deposition

(Congophilic Angiopathy)
Amyloid protein accumulates in the
walls of small arteries and arterioles
of the leptomeninges and within the
gray matter of the cerebral cortex.
These accumulations of A within the
vessel walls do not appear to clog the
vascular lumina or otherwise interfere
with the function of these vessels.

 However, when the degree of vascular involvement

is severe, there is a tendency for spontaneous
vascular rupture leading to a focal accumulation of
blood in the brain tissues. Such hemorrhages are
generally not encountered in and around the
lenticular nuclei and thalamus, such as is seen as a
result of uncontrolled systemic hypertension.
These hemorrhages tend to occur in the white
matter of the frontal and/or occipital poles, are often
small and multiple, and may be microscopic in size.
When they are large (this is a relatively rare
situation), they may be multiple and are commonly
called lobar hemorrhages. Although rare, such lobar
hemorrhages represent one of the few fatal
intracerebral complications of Alzheimer's disease.

Granulovacuolar
Degeneration
This is a poorly
understood lesion that consists of
an intraneuronal cluster of small vacuoles
measuring 2 to 4 m in diameter, each containing
a small, dense basophilic granule that typically
measures approximately 1 m in diameter.
Little is known about the nature of these lesions
or their significance. They are seen in brain
specimens derived from elderly individuals with
normal cognitive function.
large numbers of such lesions in the boundary
zone between the CA1 and CA2 regions of the
caudal aspect of the hippocampus correlate well
with a diagnosis of Alzheimer's disease

Eosinophilic Rodlike Inclusions

(Hirano Bodies)
intensely
eosinophilic
perineuronal
lesions
encountered within the CA1 region of the
hippocampus.
Identical inclusions in much smaller numbers are also
noted in some, but not all, cases of Alzheimer's
disease. Hirano bodies may also occasionally be
encountered in the brains of normal aged individuals
with intact cognition.
Hirano
bodies
have
a
very
characteristic
ultrastructural appearance consisting of parallel fibers
that interweave in a very regular crossing pattern
reminiscent of the appearance of a tweed fabric.

Synaptic Loss
Masliah and coworkers have shown a
45% loss of the extent of staining of
presynaptic boutons in cases of
Alzheimer's disease in comparison with
normal controls and have argued that
this loss of the critical element for
neuron-to-neuron
communication
constitutes the major morphological
counterpart to cognitive loss in
Alzheimer's disease.

PATHOBIOLOGY OF
ALZHEIMERS DISEASE

Amyloid Precursor Protein Processing and Generation

of A

(APP)
The cleavage
sAPP + - APP-CTF
the cleavage
A 40, A 42
Removal to Extracellular matrix
oligomerization and
aggregation
fibrils and amyloid plaques

 -secretase, also called BACE1 (betasite APP cleaving enzyme 1)

-secretase, a multimeric protein
complex
containing
presenilin,
nicastrin, Aph-1, Pen-2, and CD147.
Proteolysis of APP with secretase
result in: a large N-terminal fragment
of the protein (sAPP) that is
released in the extracellular space
and a small (12 kDa) membraneanchored fragment called - APP-CTF
(or C99).

The molecular mechanisms underlying the toxicity of A

1. Inside the brain, A is capable of forming a high-affinity
complex
with
the
neuron-associated
7-nicotinic
acetylcholine
receptor,
leading to its subsequent
endocytosis. The resulting increase in neuronal A burden
eventually causes cell lysis and ensuing extracellular
accumulation of A.
2. In addition to the nicotinic acetylcholine receptors, A binds to
a variety of other receptors, including
neurotransmitter receptors, toll-like receptors, NOD-like
receptors, formyl peptide receptors, scavenger receptors,
complement receptors, pentraxins as well as the receptor for
advanced glycation products expressed on astrocytes, microglia
and neurons.

These interactions induce the production of proinflammatory

molecules through signaling pathways, most of which involve
activation of microglia, and eventually culminate in neuronal
death

another molecular mechanisms

of the neurotoxicity
the C-terminal tail of APP can undergo further
processing at amino acid 664 of APP695
liberating two small cytosolic fragments, Jcasp
(from aa. 649 to 664 of APP695) and C31
(containing the last 31 amino acids of the Cterminus of APP, from aa. 665 to 695). Both
these fragments are generated only after
cleavage, require caspase-mediated processing
of APP, and can activate proapoptotic
pathways in a variety of cellular systems

RECENT ADVANCES IN
DIAGNOSIS

Biomarkers
Researchers hope to discover an
easy and accurate way to detect
Alzheimer's before these devastating
symptoms begin.

Brain Imaging/ neuroimaging

1. Structural
2. Functional
3. Molecular

A) Structural imaging
studies have shown that the brains of people
with Alzheimer's shrink significantly as the
disease progresses.
Research has also shown that shrinkage in
specific brain regions such as the
hippocampus may be an early sign of
Alzheimer's.
However, scientists have not yet agreed
upon standardized values for brain
volume
that
would
establish
the
significance of a specific amount of shrinkage
for any individual person at a single point in
time.

QUANTITATIVE MAGNETIC RESONANCE

IMAGING BIOMARKERS

1. VOLUMETRIC MAGNETIC RESONANCE IMAGING:

. Medial temporal regions, such as the entorhinal
cortex and hippocampus, are typically affected
earliest.
. Later on, atrophy affects lateral temporal as well as
medial and
lateral parietal association cortex
followed by frontal regions and, finally, primary
sensorimotor cortices.
. So, It is not surprising that the hippocampus has been
targeted
as the structure most likely to provide a
reliable volumetric biomarker of neurodegeneration in
AD. However, hippocampal atrophy is not specific to AD,
nor is all
AD associated with severe hippocampal
atrophy

Identifying the cut off

volume
The effects of age and intracranial volume, and
possibly gender and race, must be accounted for.
An individuals prior history of brain trauma,
alcoholism, drug abuse, and vascular risk factors
such as hypertension and smoking, would also
likely influence the measure, so it is unlikely that
a distinct cutoff in hippocampal volume
could be identified that will reliably predict AD
risk across patients.
However results showed a volume loss of 20% in
the hippocampus already present at a mild stage
of AD dementia.(Karow DS et al. 2010)

Volumetric assessment of combined

regions
The combination of regions, naturally, improves classifier
sensitivity and specificity beyond that achieved through
the use of a single region.
However, derivation of regional cortical volume or
thickness is more challenging and computationally
expensive than derivation of volumes for most subcortical
structures, such as the hippocampus and ventricular
subregions.
Hippocampal and wider medial temporal lobe (MTL)
degeneration is often associated with expansion of the
temporal horn of the lateral ventricle. Therefore,
temporal horn volumetry with comparison to normative
values could support that the individuals hippocampus
was previously larger and had undergone degeneration,
as opposed to having been congenitally small.

 2. diffusion tensor imaging (DTI)

An assessment of white matter fibers using
the imaging technique of DTI has revealed
that
the
fibers
connecting
the
hippocampus and posterior cingulate
gyrus are impaired in AD).
The most commonly used index is fractional
anisotropy (FA) that is determined by the
degree of directionality (anisotropy) of the
movement of the water molecules. A reduced
FA value is reflective of axonal degradation
and myelin damage in the brain.
However, it remains to be seen whether it
can be affected in preclinical stage.

B)Functional imaging

functional MRI:Types:

task-dependent fMRI and task-free,

or resting-state, fMRI (rsfMRI).
the blood oxygenation dependent (BOLD) signal is
used to measure blood flow and blood oxygenation,
which is believed to correlate with changes in neuronal
activity at a time scale of a few seconds
POSITRON

IMAGING):

EMISSION

TOMOGRAPHY

(FLUORODEOXYGLUCOSE

measures of brain glucose metabolism and

cerebral blood flow are markers of synaptic
dysfunction, typically obtained during resting state, but
can be task dependent. A characteristic pattern of
hypometabolism in the temporoparietal region of
the cortex, which is involved in episodic memory
function, is present at the AD dementia stage

Preclinical imaging
FDG-PET hypometabolism in a subset of cognitively
normal subjects that carry the ApoE 4 allelle have
detected changes in a subset of regions affected in
AD and these changes predict progression to MCI
Functional
MRI:
Hyperactivation
within
the
hippocampus memory network during memory
performance occurs early in the MCI phase but
reduced hippocampus activation is visible shortly
before progressing to dementia, suggesting that such
hippocampus hyperactivation is a transient
sign impending clinical worsening.
Therefore, resting state fMRI may be a more sensitive
measure than FDG PET to detect early changes
associated with AD pathology

C) Molecular imaging technologies

are among the most active areas of research aimed at finding new
approaches to diagnose Alzheimer's in its earliest stages. Molecular
strategies may detect biological clues indicating Alzheimer's is
under way before the disease changes the brain's structure or
function, or takes an irreversible toll on memory, thinking and
reasoning. Molecular imaging also may offer a new strategy to
monitor disease progression and assess the effectiveness of
next-generation, disease-modifying treatments.
Several molecular imaging compounds are approved: a radioactive
tracer binds to beta-amyloid in the brain. It can be visualized during a
positron emission tomography (PET) brain scan, thereby revealing the
presence of amyloid plaques in the brains of living patients.
1. In 2012, the U.S. Food and Drug Administration approved the first
molecular imaging tracer for (brand name Amyvid but also known as
florbetapir F-18) PiB-PET
2. A second molecular imaging tracer (brand name Vizamyl but also
known as flutametamol F18) was approved in 2013.
3. A third molecular imaging tracer (brand name Neuraceq but also
known as florbetaben F18) was approved in 2014

 amyloid imaging is not recommended

for routine use in patients suspected of
having Alzheimer's disease.
A Task Force of the Society of Nuclear
Medicine and Molecular Imaging
(SNMMI) and the Alzheimer's
Association has published criteria in
which they believe the use of amyloid
imaging would be appropriate

Appropriate for
1. Patients with persistent or progressive
unexplained MCI
2. Patients satisfying clinical criteria for
possible AD because of unclear clinical
presentation, either an atypical clinical
course or an etiologically mixed
presentation
3. Patients with progressive dementia and
atypically early age of onset (usually
defined as 65 years or less in age)

Not appropriate for

1. Patients with core clinical criteria for probable AD with
typical age of onset
2. To determine dementia severity
3. Based solely on a positive family history of dementia
or presence of apolipoprotein E ( APOE ) 4
4.
Patients with a cognitive complaint that is
unconfirmed on clinical examination
5. Instead of genotyping for suspected autosomal
mutation carriers
6. In asymptomatic individuals
7. Nonmedical use (e.g., legal, insurance coverage, or
employment screening)

 Neuroimaging methods are capable of

detecting substantial brain changes not
only in subjects with AD dementia, but
also in subjects in the mildly symptomatic
MCI due to AD and even in cognitively
normal subjects who may be in the
preclinical stage of AD

CSF MARKERS

 Amyloid Beta
42 levels are decreased in
cerebrospinal fluid of Alzheimers
disease patient (Frosch et al., 2010).
However, A-40 is unchanged. In order
to find a biomarker which is more
specific,
Ab42/AB40
ratio
was
calculated and found to be useful in
early and clinical phases of Alzheimers
disease

 CSF-Tau:
Increased CSF-tau is present during the
whole course of the disease in
Alzheimers disease which suggests
that it may be present before the onset
of clinical dementia.
elevations of t-tau (total tau) and p-tau
(phosphorylated tau) 181, are sensitive
indicators of presymptomatic disease

Combined CSF tau, A-42

CSF ratio of phospho-tau to A-42 is
more useful and can be
recommended as an aid for
evaluating individuals suspected of
dementia due to Alzheimers disease

Pre clinical stage

In MCI: Abnormal levels for A-42 (<495pg mL1) and tau (>356 pg mL-1) were accompanied
by
increased
risks
for
progression
to
Alzheimers disease
Approximately 90 percent of patients with mild
cognitive
impairment
and
pathologic
cerebrospinal fluid biomarkers will develop
Alzheimers disease within 9.2 years. Therefore,
these markers can identify individuals at high
risk for future Alzheimers disease least five to
ten years before conversion to dementia.

PLASMA MARKERS

 A42 levels, A40 levels , A42 /40

about 26 investigations have been performed to evaluate
both A40 and A42 as useful diagnostic markers.
However, the results of these studies were contradictory
because some report an association between a decline in
plasma A40 and A42 levels as well as in the A42/A40
ratio with development of AD, while other studies found no
correlation between plasma A and AD.
factors associated with A plasma levels are age,
creatinine levels, high density lipoproteins, body mass
index, race and sex.
Like CSF levels, plasma levels show a circadian fluctuation.
Therefore, standardization of sampling time is important.
further clinical research and assay development are
needed before measures of plasma A can be interpreted
as biomarkers for AD.

PLASMA TAU FORMS

using classic systems tau is virtually undetectable
in MCI and/or AD.
Recently, an ultra-sensitive immunoassay for
quantification of tau protein in serum samples
was published and is based on antibodies reacting
with all tau isoforms, both normal and
phosphorylated tau.
Preliminary data also show increased serum tau
levels in AD patients, with about twice as high
levels as in cognitively normal elderly. These data
suggest that serum tau may have a potential as a
screening tool for the identification of AD

PLASMA PROTEOMICS
18-plasma protein profile, consisting of endocrine and
hormone-like proteins, which identified AD patients
from controls with a high specificity. But clinically
significant protein markers of AD did not replicate
across cohorts.
NT-proBNP, CRP, pancreatic polypeptide, fatty acid
binding protein, etc.
plasma Beta-site APP Cleaving Enzyme (BACE-1), and
soluble forms of Amyloid Precursor Protein were found
to significantly elevated in plasma from AD patients,
which may offer diagnostic value in AD.
cystatin C, A1AcidG, ICAM1, CC4, pigment
epithelium-derived factor [PEDF], A1AT, RANTES,
ApoC3) were strongly associated with disease
severity and disease progression
These markers were characterized by a good

 complement factor H [CFH] and alpha-2macroglobulin [A2M]) serum amyloid P

(SAP),
complement
C4
(CC4),
and
ceruloplasmin, all of which have been
implicated in AD pathogenesis.

Clusterin, also known as apolipoprotein J,

is a heterodimeric glycoprotein expressed
in the majority of mammalian tissues is
associated with hippocampal atrophy and
clinical progression.
Transthyretin (TTR) and apolipoprotein A1
(ApoA1) to be associated with faster
declining AD subjects

 Neuronal and glial derived proteins (such as S100B

have also been studied in this regard. Glial derived
protein S100B (S100 calcium binding protein B) is
responsible for, proliferation of melanoma cells,
neurite extension stimulation of Ca2+fluxes,
astrocytosis and axonal proliferation, inhibition of
PKC-mediated phosphorylation and inhibition of
microtubule assembly.

In a developing brain it functions as a

neurotrophic factor and neuronal survival protein.
Hence, serum levels of S100B are studied as a
marker for brain functional condition reflect
morphological status in AD. serum levels of S100B
are significantly reduced with a positive correlation
between S100B levels and AD severity.

 Individual blood biomarkers have been

unsuccessful in defining the disease
pathology,
progression
and
thus
diagnosis. This directs to the need for
discovering a multiplex panel of blood
biomarkers as a promising approach
with high sensitivity and specificity for
early diagnosis

Biomarkers associated with vascular

risk, metabolic and inflammation states
Total cholesterol:
Evidence from cell culture and animal studies
demonstrate that the production, aggregation,
deposition and recycling of cerebral A as well as its
neurotoxicity may be modulated by cholesterol.
However, we still do not have a complete
understanding of how cholesterol levels can
influence AD pathogenesis, and despite early
evidence from observational studies that cholesterol
lowering by statins might reduce the risk of
dementia.

Oxysterols
The brain eliminates excess cholesterol by
excreting two oxidized oxysterols into the
circulation: 24Shydroxycholesterol and 27hydroxycholesterol
Levels of 24S-hydroxycholesterol appear to
reflect brain production (and number of
neurons) as well as hepatic elimination.
Although evidence suggests that oxysterols
play a role in AD pathogenesis by interacting
with A and regulating astrocytic production of
APOE, the precise mechanisms are not clear.
data on the association of circulating
oxysterols with incident dementia are scarce.

 Homocysteine, vitamins B12 and

folate, and related metabolites:
Plasma homocysteine and methylmalonic
acid, and more recently holotranscobalamin,
have been shown to be better indicators of
vitamin B12 status and associated with risk
of incident dementia and AD.
Considerable evidence suggests that an
elevation of total plasma homocysteine
(tHcy) is associated with a subsequent
higher risk of AD. The mechanisms
underlying this association remain uncertain
and it is not clear whether tHcy is an AD risk
factor or merely a risk marker.

Possible mechanisms:
1. Homocysteine promotes calcium influx and generation of
toxic free oxygen radicals, thus accelerating DNA damage
within hippocampal neurons
2. A metabolite of homocysteine, homocysteic acid,
activates excitotoxic glutamatergic N-methyl-D-aspartate
receptors
3. Elevated tHcy levels promote the homocysteinylation of
proteins, thus altering protein function
4. inhibit Na+/K+-ATPase activity
5. Homocysteine
increases
presenilin-mediated
A
generation and potentiates the neurotoxicity of insoluble
A deposits
6. promotes tau hyperphosphorylation
7. Homocysteine could increase dementia risk via its
vasculotoxic effects on large arteries

Insulin and amylin

Diabetes is associated with a higher risk of dementia,
possibly due to dysfunction in insulin signaling pathways in
the brain since peripheral and perhaps central insulin
resistance is a defining characteristic of type 2 diabetes.
The
mechanisms
underlying
the
insulindementia
association are not clear, and may include decreased
clearance of A by the insulin-degrading enzyme
(which preferentially binds insulin but has a physiological
role
in
A
clearance),
increased
tau
hyperphosphorylation, or an indirect effect such as
potentiating vascular injury or the adverse effects of
inflammation.
Amylin, or islet amyloid polypeptide, an amyloidogenic
peptide hormone produced by the pancreas along with
insulin, was recently shown to be present in the brains of
persons with AD but a prospective association of circulating
amylin levels and risk of AD has not been demonstrated.

PLATELET MEMBRANE
PROTEOME AS A SOURCE OF
PERIPHERAL BIOMARKERS
FOR ALZHEIMERS DISEASE

platelets share many similarities with synaptic

terminals in neurons and have been used as a
model for studying synaptic vesicle metabolism.
1. both platelets and neurons secrete and respond to
neurotransmitters and share many of the same
secretory
pathways
and
transporters
for
neurotransmitter uptake and packaging.
2. Platelets also contain a high concentration of amyloid
precursor protein (APP) and possess , , and
secretases.
3. Increased levels of activated platelets have been
reported in patients with early AD compared to
healthy, age-matched controls, and the platelet
activation state has been positively correlated with
the rate of cognitive decline measured by the mini
mental status exam (MMSE). However, some studies
[JAREMO et al., 2012] reported a decrease in platelet

Whole platelet proteome and subproteomes have been

profiled using liquid chromatography coupled with
tandem mass spectrometry (LC-MS/MS)

144 proteins were determined significantly altered in

the platelet membrane proteome in patients with
probable AD.
In particular, proteins encompassing the -secretory
granule pathway including , , and -chains of
fibrinogen,
thrombospondin-1
(THBS1),
von
Willebrand
factor
and
fibronectin
were
dramatically reduced in AD.

LYMPHOBLAST

Calmodulin in lymphoblast
There is a functional relationship between
Ca2+/calmodulin (CaM) and the main signaling
pathways controlling cell survival or death
depending upon growth factor availability. current
evidence relates the process of neuronal apoptosis
occurring in AD to the aberrant re-entry of
differentiated neurons into the cell cycle
Researches detected significantly increased
levels of CaM in AD lymphoblasts.
CaM level was higher in AD > MCI> controls. Thus
it is considered a useful biomarker to help in early
diagnosis of AD, enabling one to discriminate AD
from other dementias with high levels of sensitivity
and specificity.

BUCCAL CELLS
ASSOCIATED ALZHEIMER
MARKERS

Buccal micronucleus cytome

biomarkers
Frequencies of basal cells (P < 0.0001),
condensed chromatin cells (P < 0.0001)
and karyorrhectic cells (P < 0.0001) were
found to be significantly lower in
Alzheimers patients.
These changes may reflect alterations in
the cellular kinetics or structural profile of
the buccal mucosa, and may be useful as
potential
biomarkers
in
identifying
individuals with a high risk of developing AD

Altered Cytological Parameters in Buccal

Cells(Francois et al.,2014)
An automated buccal cell assay was developed using laser scanning
cytometry (LSC) to measure buccal cell type ratios, nuclear DNA
content and shape, and neutral lipid content of buccal cells.
DNA content was significantly higher in all cell types in both MCI
(P<0.01) and AD (P<0.05) compared with controls.
Abnormal nuclear shape (circularity) was significantly increased in
transitional cells in MCI (P<0.001) and AD (P<0.01) when
compared to controls.
In contrast, neutral lipid content (as measured by Oil red O ORO
staining) of buccal cells was significantly lower in the MCI group
(P<0.05) compared with the control group.
The ratio of DNA content/ORO in buccal basal cells for both MCI
and AD was significantly higher compared to the control group.
The changes in the buccal cell cytome observed in this study could
prove useful as potential biomarkers in identifying individuals with
an increased risk of developing MCI and eventually AD.

OLFACTORY EPITHELIUM

 Anosmia or olfactory dysfunction resulting in loss

of smell is common in neurodegenerative diseases
such as Parkinsons or AD and may appear as one of
the early symptoms.
Furthermore, olfactory dysfunction has been found to
be commonly associated with memory deficiency in
transgenic mouse models of AD.
the olfactory epithelium exhibited increased
oxidative damage in AD. HNE-pyrrole (a product of
lipid oxidation) and heme oxygenase-1 (a catalytic
enzyme involved in degradation of heme) levels were
found to be increased in neurons and epithelial cells
from olfactory biopsy sections in AD compared to
healthy controls.
Immunohistochemistry showed Increased levels of A
and hyperphosphorylated Tau were also observed in
the olfactory epithelium in AD.

 Many different biomarkers in different

peripheral tissues were examined and
contradictory results were obtained.
This is an important field of ongoing
research.
Hopefully
simple
non
invasive biomarker will be found.

RECENT ADVANCES IN
TREATMENT

 The symptomatic drugs currently on

the market for Alzheimers disease
(AD) have no effect on disease
progression

 Therapeutic Targets Focusing on A

Cascade Hypothesis:
Inhibition of A Production:
-Secretase (BACE1) Inhibitor: further testing
indicated that the drastic inhibition would
result in hypomyelination and behavioral
abnormalities such as seizures. This is
because, except from APP, BACE1 has a
series of substrates, like neuregulin-1,
related to myelination (Thiazolidinediones
can activate PPAR to inhibit -secretase and
promote ubiquitination to degrade amyloid
load. MK- 8931, LY2886721 are in phase 1
trial

 -Secretase
Inhibitors
(GSI)
and
Modulators Several -secretase inhibitors
(GSIs) have been launched in clinical trials.
Many reduced the A production in plasma or
CSF but few successfully avoided the sideeffects. Haematological and gastrointestinal
toxicity, skin reactions, and changes to hair color
Semagacestat is the first - secretase inhibitor
that have been taken into Phase 3 clinical trials.
however they were discontinued due to
increased risk of skin cancer and infection and
lack of efficacy
Avagacestat (BMS-708163), begacestat,
and NIC5-15 are such Notch-sparing GSIs
under clinical trials.

 the concept of -secretase modulators (GSMs) was

established with the expectation of nonsteroidal antiinflammatory drugs (NSAIDs). A subset of NSAIDs, like
ibuprofen, indomethacin, and sulindac sulfide,
disconnected from their cyclooxygenase (COX)
properties were discovered to be able to selectively
reduce the production of A42 at the cost of elevated
shorter peptide A38. This finding promoted the GSMs
as promising therapeutic candidates for Alzheimers
disease, however, clinical trials were disappointing.
The weak potency of tarenflurbil can be attributable
to low CNS penetrationas shown in phase 1 trial
Another GSM CHF-5074 based on R-flurbiprofen
ameliorated brain A load and improved the animals
performance in behavior tests. The drugs safety and
tolerability have been evaluated and are undergoing a
phase 2 trial.

-Secretase Activator.

Agonists of muscarinic, glutamate, and serotonin receptors,

statins, oestrogens, testosterone, and protein kinase C
activators belong to this drug classification that can motivate
-secretase activity, and they have been launched in clinical
trials, but data indicating their use in AD is limited.
Etazolate (EHT-0202), a selective GABAA receptor modulator,
has completed a phase 2 trial in patients with mild to
moderate AD.
Bryostatin-1, a macrocyclic lactone, caused a decline of
brain A40/42, improved behavior test in AD mouse model
and was under a phase 2 trial, but the specific information is
inaccessible.
A follow-up study evaluating one year simvastatin treatment
in 120 cognitively normal and middle aged adults, effect on
CSF levels of A42, t-tau, and p-tau181, is ongoing.

Anti--Amyloid Aggregation

Antiaggregates.
Metal Complexing Agents
Active Immunization
Passive Immunization

Antiaggregates
1. tramiprosate,
derived
from
proprionic
acid
demonstrated poor CNS penetration and the weak
potency.
2. Scyllo-inositol is thought to effectively impede A
aggregation, promote misfolding, modulation, and
accelerate aggregates disassociation, can cross
blood brain barrier, in phase 2trials.
3. Epigallocatechin-3-gallate (EGCg), a polyphenol
from green tea, via disrupting unfolded peptide,
stimulated -secretase activity and inhibited A
aggregation in animal models, a phase 3 trial with
early AD patients with EGCg is being conducted.

Metal Complexing Agents.

After A peptides were produced and released into
extracellular fluids, metals like Zn and Cu can motivate
oligomerization into fibrils, so chelators or metal
complexing agents that can interfere with reaction of
metal ions with A are likely to be a therapeutic
strategy.
Clioquinol (PBT2), metal-induced A inhibitors, also
has a potent CNS permeability. PBT2 can redistribute
metal ions to neurons promoting metalloproteinase
expression and thus an increment of A degradation. A
phase 2 trial was completed and it proved a decrease
of A42 concentration in CSF and an improvement of
cognitive and behavioral performance

active immunization
In 1999, Schenk et al published the first active
immunization study in transgenic mouse model.
Initial findings revealed a reduction of plaque
deposition in aged mice after administration of
A-42. Treatment in young mice prevented A
plaque formation. No signs of damage were
observed in the brains of treated animals.
Later, two other groups reported the immunization
of different AD mouse models using aggregated
A-42 improvement in cognition was observed by
evaluation with the Morris water maze which
correlated with reduction of amyloid plaque burden.

 Not only full A142 immunizations

effective, but fragments of A
peptide including tandems of A(1
15) also induced reduction of plaque
load and lowered levels of A-40 and
A-42 in the brain, which correlated
with an efflux of A to the blood.
Complications
for
A
immunization, included microbleeds
and iron deposits in the choroid plexus

Passive immunization
Studies in mice immunized with mouse
monoclonal antibodies against A
peptide indicated that the antibody
can cross the bloodbrain barrier and
reduce amyloid plaques as well as
levels of soluble A-42.

Summary of clinical trials of immunization

 According to reports published in the New

England Journal of Medicine, the phase 3
clinical
trials
of
two
high-profile
Alzheimers disease (AD) antibodies
against the aggregation-prone peptide
amyloid beta (A), bapineuzumab and
solanezumab, have failed to improve
clinical outcomes in patients with late
onset AD (2014)

SMER28: accelerating the breakdown

of beta-amyloid by autophagy
autophagy is a process reduces the buildup of beta amyloid
in isolated cells and might be utilized to eliminate the buildup
of beta-amyloid in the brains of Alzheimers patients.
Autophagy is a process cells use to clean out the debris
from their interiors, including unwanted materials such as the
protein aggregates that are hallmarks of Alzheimers disease.
The scientists discovered that a compound called SMER28
lowers the level of beta-amyloid found in nerve cells. This
occurs because SMER28 stimulates autophagy, which then
rids the cell of beta-amyloid.

TARGETING TAU

 Inhibit abnormal phosphorylation

Inhibit aggregation

Kinase Inhibitors
Protein kinase, a group of critical enzymes responsible for tau
overphosphorylation, is a prerequisite for the tau-induced
toxicity.
redundancy of kinase interactions and uncertainty of which
enzyme specifically catalyzes the phosphorylation that we
are focusing on, are major challenges in research.
glycogen synthase kinase 3 beta appears to engage in
AD pathogenesis given its impact on cellular signaling and
gene description, it is responsible for 31% of the pathological
phosphorylation sites of tau protein.
Lithium and valproate reduced tau phosphorylation and
prevented reversed aspects of tauopathy in animal models
but did not show cognitive improvement in clinical trials with
AD patients.
Development of some paullone, indirubin, and maleimide
family-derived GSK3 inhibitors is stuck in the preclinical
trials concerning the cytotoxic effects.

 Cyclin dependent kinase 5 (cdk5) is another

kinase tightly associated with tau pathology.
Cdk5 regulating protein was found in AD brain
and
thus
is
probably
causing
a
pathophysiological tau phosphorylation .
Cdk5-selective inhibitors were demonstrated to
penetrate BBB and reduce elevated A level by
regulating cdk5and are at preclinical status.
The test of several compounds targeting other
protein kinases, like cdk1/2/9, p38, Erk1/2, JNK,
casein kinase, and DYRKIA brought disappointing
outcomes, and trials were discontinued due to
the poor efficacy or severe adverse effects.

Inhibition of Tau Aggregation

Methylene blue) is a tau antiaggregant. Preclinical
data revealed a learning deficit reversing property
and a completed phase 2 trial proved that this
agent can slow down AD progression with a good
bioavailability.
TRx0237, another methylene blue, has an
improved drug absorption, bioavailability, and
tolerability. Since 2008, intensive investigation of
this agent began, and growing evidence indicated
that TRx0237 benefits neuroprotection and A
clearance in transgenic mice and improves spatial
learning in rats. The antiaggregation properties
were reported by some papers, and three phase 3
studies are ongoing.

 Epothilone D (BMS-241027) is a microtubule

stabilizer, via inhibition of tau release from
microtubule to maintain the transportation function
of axon, and on the other hand, precludes formation
of tau aggregation. This agent restored behavioral
and cognitive deficits, inhibited neuron loss, and
curbed the tauopathy in animal models. Epothilone
can penetrate BBB and exert a better efficacy at low
concentration and now undergoes a phase 1 clinical
trial
Nicotinamide, the precursor of coenzyme NAD+,
reduces
phosphorylated
tau
and
protects
microtubules
stabilization
in
mouse
model.
Nicotinamide has been launched into clinical studies
suggesting that it is safe and well tolerated and a
phase 2 clinical trial is ongoing in patients with mildto moderate Alzheimers disease.

TARGETING
NEUROTRANSMITTERS

 EVP-6124, a selective agonist of the -7

nicotinic acetylcholine receptor, has
finished a phase 2 trial showing safe
and
well
tolerated
results
and
recently(Oct 2013) entered two phase
3 trials to test the cognitive benefits.
Quite a few other clinical trials testing
nicotinic
agonists
are
ongoing
(ladostigil
hemitartrate,
phase
2;
ispronicline, phase 1), completed
(RO5313534), or terminated (ABT-089).

 A transmitter that indirectly modulates neuron

degeneration and memory deficits is serotonin
(5-HT). Growing evidence indicated that inhibition
of 5-HT6 could facilitate Ach release and via
elevated cholinergic transmission, memory and
learning defects were likely to be ameliorated.
5-HT6 antagonists were widely reported in
many studies to rescue anticholinergic drugsinduced amnesia .Recently, two agents, PRX03140(5-HT4 antagonist) and SB-742457(5-HT6
antagonist), completed the phase 2 trials. Lu
AE58054, an antagonist of the serotonin 6 (5-HT6)
receptor was recently progressed into a phase 3
trial with 930 mild to moderate AD patients in
combination with AchE inhibitor donepezil.

NGF

Neurotrophin
Nerve growth factor (NGF) as a neurotrophin plays a
critical role promoting survival and maintaining the
function of cholinergic neurons. In AD patients,
transcription and translation levels of NGF were
changed. suggesting that NGF supplementation probably
is a treatment approach for Alzheimers disease. NGF
with unfavorable size and polarity is a peptide that
cannot cross,, so to safely and efficiently deliver it to the
brain will be a great challenge. However, efforts have
been made to overcome this obstacle.
An example of strategy is as follows: CERE-110 uses
adeno-associated virus to transfer a gene that makes
NGF and is injected into AD patients brain. This
approach undergoes a phase 2 study.

OTHERS

WAVE 1
WAVE 1 is a protein and a key regulator
of connections between brain cells. It
controls the formation of new cell
connections which influence thinking
and behavior. This knowledge will one
day allow doctors to administer drugs
that may either prevent the loss of brain
cell connections in Alzheimers or
stimulate the growth of new connections
to restore memory and lost function.

delta-9tetrahydrocannabinol
University of South Florida (USF
Health)
Extremely low levels of the
compound in marijuana known as
delta-9-tetrahydrocannabinol, or
THC, may slow or halt the
progression of Alzheimer's disease, a
recent study.2014

Microglia targeted therapy

Researchers at Standford University discovered that nerve
cells die because cells which are supposed to clear the brain
of bacteria, viruses and dangerous deposits, stop working.
These cells, called 'microglia' function well when people are
young, but when they age, a single protein called EP2 stops
them operating efficiently.
Now scientists have shown that blocking the protein allows
the microglia to function normally again so they can hoover
up the dangerous sticky amyloid-beta plaques which
damage nerve cells in Alzheimer's disease.
The researchers found that, in mice, blocking EP2 with a
drug reversed memory loss and myriad other Alzheimerslike features in the animals.
Now Stanford is hoping to produce a compound which only
blocks EP2 to prevent unnecessary side effects.

REFERENCES

1. Qiutian Jia, et al., Potential Therapeutic Strategies for

Alzheimers Disease Targeting or Beyond -Amyloid:
Insights
from
Clinical
Trials.
BioMed
Research
International.2014
2. Castello et al., Moving beyond anti-amyloid therapy for the
prevention and treatment of Alzheimers disease. BMC
Neurology 2014, 14:169.
3. Abdul Hye et al., Plasma proteins predict conversion to
dementia from prodromal disease. Alzheimers & Dementia
10 (2014) 799-807.
4. Thomas etal., Buccal micronucleus cytome biomarkers may
be associated with Alzheimers disease. Mutagenesis vol. 22
no. 6 pp. 371379, 2007.
5. Gupta et al., Multiplex biomarkers in blood. Alzheimers
Research & Therapy 2013, 5:31.
6. Donovan et al., Exploring the potential of the platelet
membrane proteome as a source of peripheral biomarkers
for Alzheimers disease. Alzheimers Research & Therapy
2013, 5:32
7. Esteras et al., Calmodulin levels in blood cells as a potential
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