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Valizadeh P, Momtazmanesh S, Plazzi G, Rezaei N. Connecting the dots: An updated review of the role of autoimmunity in narcolepsy and emerging immunotherapeutic approaches. Sleep Med 2024; 113:378-396. [PMID: 38128432 DOI: 10.1016/j.sleep.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/08/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Narcolepsy type 1 (NT1) is a chronic disorder characterized by pathological daytime sleepiness and cataplexy due to the disappearance of orexin immunoreactive neurons in the hypothalamus. Genetic and environmental factors point towards a potential role for inflammation and autoimmunity in the pathogenesis of the disease. This study aims to comprehensively review the latest evidence on the autoinflammatory mechanisms and immunomodulatory treatments aimed at suspected autoimmune pathways in NT1. METHODS Recent relevant literature in the field of narcolepsy, its autoimmune hypothesis, and purposed immunomodulatory treatments were reviewed. RESULTS Narcolepsy is strongly linked to specific HLA alleles and T-cell receptor polymorphisms. Furthermore, animal studies and autopsies have found infiltration of T cells in the hypothalamus, supporting T cell-mediated immunity. However, the role of autoantibodies has yet to be definitively established. Increased risk of NT1 after H1N1 infection and vaccination supports the autoimmune hypothesis, and the potential role of coronavirus disease 2019 and vaccination in triggering autoimmune neurodegeneration is a recent finding. Alterations in cytokine levels, gut microbiota, and microglial activation indicate a potential role for inflammation in the disease's development. Reports of using immunotherapies in NT1 patients are limited and inconsistent. Early treatment with IVIg, corticosteroids, plasmapheresis, and monoclonal antibodies has seldomly shown some potential benefits in some studies. CONCLUSION The current body of literature supports that narcolepsy is an autoimmune disorder most likely caused by T-cell involvement. However, the potential for immunomodulatory treatments to reverse the autoinflammatory process remains understudied. Further clinical controlled trials may provide valuable insights into this area.
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Affiliation(s)
- Parya Valizadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Sara Momtazmanesh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Giuseppe Plazzi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy; Department of Biomedical, Metabolic, and Neural Sciences, Università Degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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2
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Yamada R, Narita N, Ishikawa T, Kakehi M, Kimura H. The orexin receptor 2 (OX2R)-selective agonist TAK-994 increases wakefulness without affecting cerebrospinal fluid orexin levels in cynomolgus monkeys. Pharmacol Biochem Behav 2024; 234:173690. [PMID: 38061670 DOI: 10.1016/j.pbb.2023.173690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 01/01/2024]
Abstract
Orexin A (OX-A) and orexin B are neuropeptides produced in orexin neurons located in the lateral hypothalamus that exert multiple biological functions through the activation of orexin receptor 1 (OX1R) and orexin receptor 2 (OX2R) throughout the central nervous system. OX1R and OX2R have distinct functions: OX1R is involved in reward seeking, whereas OX2R has a pivotal role in sleep/wake regulation. OX2R-selective agonists are in development as novel therapeutic agents for the treatment of hypersomnia. However, their potential to induce orexin release, which may indirectly stimulate both OX1R and OX2R in vivo, is unclear. Herein, we assessed the effects of the OX2R-selective agonist TAK-994 on wakefulness and orexin release in monkeys. Oral administration of TAK-994 at 10 mg/kg in the beginning of the sleep phase (zeitgeber time [ZT] 12) significantly increased wakefulness time in monkeys but did not increase OX-A levels in monkey cisternal cerebrospinal fluid (CSF). Moreover, oral administration of TAK-994 (10 mg/kg) during the active phase (ZT1) did not increase OX-A levels in monkey CSF. These findings indicate that the OX2R agonist TAK-994 selectively activates OX2R in vivo and would not robustly induce spontaneous orexin release during the daytime or nighttime in monkeys.
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Affiliation(s)
- Ryuji Yamada
- Neuroscience Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, 26-1, Muraoka-Higashi 2-Chome, Fujisawa, Kanagawa 251-8555, Japan
| | - Naohiro Narita
- Drug Metabolism and Pharmacokinetics Laboratory, Research, Takeda Pharmaceutical Company Limited, 26-1, Muraoka-Higashi 2-Chome, Fujisawa, Kanagawa 251-8555, Japan
| | - Takashi Ishikawa
- Neuroscience Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, 26-1, Muraoka-Higashi 2-Chome, Fujisawa, Kanagawa 251-8555, Japan
| | - Masaaki Kakehi
- Drug Metabolism and Pharmacokinetics Laboratory, Research, Takeda Pharmaceutical Company Limited, 26-1, Muraoka-Higashi 2-Chome, Fujisawa, Kanagawa 251-8555, Japan
| | - Haruhide Kimura
- Neuroscience Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, 26-1, Muraoka-Higashi 2-Chome, Fujisawa, Kanagawa 251-8555, Japan.
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3
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Narita N, Yamada R, Kakehi M, Kimura H. Diurnal Fluctuations of Orexin-A and -B in Cynomolgus Monkey Cerebrospinal Fluid Determined by a Novel Analytical Method Using Antiadsorptive Additive Treatment Followed by Nanoflow Liquid Chromatography-High-Resolution Mass Spectrometry. ACS Chem Neurosci 2023; 14:609-618. [PMID: 36719857 PMCID: PMC9936545 DOI: 10.1021/acschemneuro.2c00370] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Orexin-A (OXA) and -B (OXB) are involved in the regulation of multiple physiological functions including the sleep-wake states; therefore, it is critical to monitor their levels under various conditions. Unfortunately, the widely used radioimmunoassay has insufficient specificity for OXA. Although liquid chromatography-tandem mass spectrometry (LC-MS/MS) has higher specificity for OXA, previously reported OXA levels in human cerebrospinal fluid (CSF) measured using this technique are still inconsistent. Moreover, to the best of our knowledge, OXB has not been detected in the CSF. In this study, we established a novel method for OXA and OXB measurement. We noticed that OXA and OXB in the CSF was sticky; thus, citric acid and Tween 80 were used to prevent their nonspecific binding. Then, highly specific and sensitive nanoflow liquid chromatography-high-resolution mass spectrometry (nanoLC-HRMS) was used to measure OXA and OXB levels. Evaluation of the diurnal fluctuations of OXA and OXB in cisternal and lumbar CSF samples from cynomolgus monkeys revealed a sharp increase in the early light period, followed by a gradual increase to the maximum levels at the end of the light period, and then a sharp drop to the minimum levels during the early dark period. OXB levels were lower than OXA levels in cisternal CSF. Although basal OXA levels in individual monkeys showed substantial variations, the ratios between the maximum and minimum OXA levels of each monkey were similar. Our method for accurate OXA and OXB measurement should help improve our knowledge of orexin biology.
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Affiliation(s)
- Naohiro Narita
- Drug
Metabolism and Pharmacokinetics Laboratory, Research, Takeda Pharmaceutical Company Limited, 26-1 Muraoka-Higashi 2-chome, Fujisawa, Kanagawa 251-8555, Japan
| | - Ryuji Yamada
- Neuroscience
Drug Discovery Unit, Research, Takeda Pharmaceutical
Company Limited, 26-1 Muraoka-Higashi 2-chome, Fujisawa, Kanagawa 251-8555, Japan
| | - Masaaki Kakehi
- Drug
Metabolism and Pharmacokinetics Laboratory, Research, Takeda Pharmaceutical Company Limited, 26-1 Muraoka-Higashi 2-chome, Fujisawa, Kanagawa 251-8555, Japan
| | - Haruhide Kimura
- Neuroscience
Drug Discovery Unit, Research, Takeda Pharmaceutical
Company Limited, 26-1 Muraoka-Higashi 2-chome, Fujisawa, Kanagawa 251-8555, Japan,
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4
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Repeated measures of hypocretin-1 in Danish and Italian patients with narcolepsy and in controls. Sleep Med 2023; 101:213-220. [PMID: 36427467 DOI: 10.1016/j.sleep.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 09/15/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVES The assay currently used worldwide to measure cerebrospinal fluid hypocretin-1 (CSF-hcrt-1) for diagnosing narcolepsy uses a competitive radioimmunoassay with polyclonal anti-hcrt-1 antibodies. This assay detects multiple hypocretin-1 immunoreactive species in the CSF that are all derived from full-length hcrt-1. We aimed to revalidate CSF-hcrt-1 cut-offs for narcolepsy type 1 (NT1) diagnosis and to evaluate temporal changes in CSF-hcrt-1 levels in patients suspected of having central hypersomnia. METHOD We carried out a repeat lumbar puncture with a mean follow-up of 4.0 years, to measure CSF-hcrt-1 in patients suspected of having central hypersomnia in a follow-up study. Data from CSF samples of patients with NT1 and of controls without known hypersomnia, from the Italian-Stanford and Danish populations, were examined using a receiver-operating characteristic analysis. RESULTS The optimal CSF-hcrt-1 cut-offs for identifying NT1 were 129 pg/ml and 179 pg/ml for the Italian-Stanford and Danish populations, respectively. The sensitivity was 0.93-0.99 and the specificity was 1. Follow-up lumbar puncture measurements of CSF-hcrt-1 were obtained from 73 patients. 30 of 32 patients with low CSF-hcrt-1 levels continued to be categorized as low, with an unaltered diagnosis; two patients showed a marked increase in CSF-hcrt-1, attaining normal values at follow-up. One of these patients relapsed to low CSF-hcrt-1 after follow-up. All 41 patients with normal CSF-hcrt-1 at baseline had normal CSF-hcrt-1 at follow-up. CONCLUSION CSF-hcrt-1 measurement can provide an accurate test for diagnosing NT1, although it is important to validate the CSF-hcrt-1 cut-off for specific testing locations. Stable CSF-hcrt-1 levels support the already established prognosis of narcolepsy as permanent once the disorder has fully developed.
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5
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van der Hoeven AE, van Waaij K, Bijlenga D, Roelandse FWC, Overeem S, Bakker JA, Fronczek R, Lammers GJ. Hypocretin-1 measurements in cerebrospinal fluid using radioimmunoassay: within and between assay reliability and limit of quantification. Sleep 2022; 45:6581446. [PMID: 35512685 PMCID: PMC9272241 DOI: 10.1093/sleep/zsac103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/30/2022] [Indexed: 11/23/2022] Open
Abstract
Study Objectives The most sensitive and specific investigative method for the diagnosis of narcolepsy type 1 (NT1) is the determination of hypocretin-1 (orexin-A) deficiency (≤110 pg/mL) in cerebrospinal fluid using a radioimmunoassay (RIA). We aimed to assess the reliability of the Phoenix Pharmaceuticals hypocretin-1 RIA, by determining the lower limit of quantification (LLOQ), the variability around the cutoff of 110 pg/mL, and the inter- and intra-assay variability. Methods Raw data of 80 consecutive hypocretin-1 RIAs were used to estimate the intra- and inter-assay coefficient of variation (CV). The LLOQ was established and defined as the lowest converted concentration with a CV <25%; the conversion is performed using a harmonization sample which is internationally used to minimize variation between RIAs. Results The mean intra-assay CV was 4.7%, while the unconverted inter-assay CV was 28.3% (18.5% excluding 2 outliers) and 7.5% when converted to international values. The LLOQ was determined as 27.9 pg/mL. The intra-assay CV of RIAs with lower specific radioactive activity showed a median of 5.6% (n = 41, range 1.6%–17.0%), which was significantly higher than in RIAs with higher specific activity (n = 36; median 3.2%, range 0.4%–11.6%, p = .013). The CV around the 110 pg/mL cutoff was <7%. Conclusions Hypocretin-1 RIAs should always be harmonized using standard reference material. The specific activity of an RIA has a significant impact on its reliability, because of the decay of 125I radioactivity. Values around the hypocretin-1 cut-off can reliably be measured. Hypocretin-1 concentrations below 28 pg/mL should be reported as “undetectable” when measured with the Phoenix Pharmaceuticals RIA. Clinical Trial Information This study is not registered in a clinical trial register, as it has a retrospective database design
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Affiliation(s)
- Adrienne Elisabeth van der Hoeven
- Department of Neurology, Leiden University Medical Center , Leiden , the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN) , Heemstede , the Netherlands
| | - Kevin van Waaij
- Department of Neurology, Leiden University Medical Center , Leiden , the Netherlands
| | - Denise Bijlenga
- Department of Neurology, Leiden University Medical Center , Leiden , the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN) , Heemstede , the Netherlands
| | | | | | - Jaap Adriaan Bakker
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center , Leiden , the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center , Leiden , the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN) , Heemstede , the Netherlands
| | - Gert Jan Lammers
- Department of Neurology, Leiden University Medical Center , Leiden , the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN) , Heemstede , the Netherlands
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6
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Orexin 2 receptor (OX2R) protein distribution measured by autoradiography using radiolabeled OX2R-selective antagonist EMPA in rodent brain and peripheral tissues. Sci Rep 2022; 12:8473. [PMID: 35589803 PMCID: PMC9120030 DOI: 10.1038/s41598-022-12601-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/13/2022] [Indexed: 11/18/2022] Open
Abstract
Orexin, a neuropeptide, performs various physiological functions, including the regulation of emotion, feeding, metabolism, respiration, and sleep/wakefulness, by activating the orexin 1 receptor and orexin 2 receptor (OX2R). Owing to the pivotal role of OX2R in wakefulness and other biological functions, OX2R agonists are being developed. A detailed understanding of OX2R protein distribution is essential for determining the mechanisms of action of OX2R agonists; however, this has been hindered by the lack of selective antibodies. In this study, we first confirmed the OX2R-selective binding of [3H]-EMPA in in vitro autoradiography studies, using brain slices from OX2R knockout mice and their wild-type littermates. Subsequently, OX2R protein distribution in rats was comprehensively assessed in 51 brain regions and 10 peripheral tissues using in vitro autoradiography with [3H]-EMPA. The widespread distribution of OX2R protein, including that in previously unrecognized regions of the retrosplenial cortex, was identified. In contrast, OX2R protein expression was negligible/very low in peripheral tissues, suggesting that orexin exerts OX2R-dependent physiological functions primarily through activation of the central nervous system. These findings will be useful for understanding the wide range of biological functions of OX2R and the application of OX2R agonists in various disorders.
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7
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Abstract
The hypocretins (Hcrts), also known as orexins, are two neuropeptides produced exclusively in the lateral hypothalamus. They act on two specific receptors that are widely distributed across the brain and involved in a myriad of neurophysiological functions that include sleep, arousal, feeding, reward, fear, anxiety and cognition. Hcrt cell loss in humans leads to narcolepsy with cataplexy (narcolepsy type 1), a disorder characterized by intrusions of sleep into wakefulness, demonstrating that the Hcrt system is nonredundant and essential for sleep/wake stability. The causal link between Hcrts and arousal/wakefulness stabilisation has led to the development of a new class of drugs, Hcrt receptor antagonists to treat insomnia, based on the assumption that blocking orexin-induced arousal will facilitate sleep. This has been clinically validated: currently, two Hcrt receptor antagonists are approved to treat insomnia (suvorexant and lemborexant), with a New Drug Application recently submitted to the US Food and Drug Administration for a third drug (daridorexant). Other therapeutic applications under investigation include reduction of cravings in substance-use disorders and prevention of neurodegenerative disorders such as Alzheimer's disease, given the apparent bidirectional relationship between poor sleep and worsening of the disease. Circuit neuroscience findings suggest that the Hcrt system is a hub that integrates diverse inputs modulating arousal (e.g., circadian rhythms, metabolic status, positive and negative emotions) and conveys this information to multiple output regions. This neuronal architecture explains the wealth of physiological functions associated with Hcrts and highlights the potential of the Hcrt system as a therapeutic target for a number of disorders. We discuss present and future possible applications of drugs targeting the Hcrt system for the treatment of circuit-related neuropsychiatric and neurodegenerative conditions.
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Affiliation(s)
- Laura H Jacobson
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia.,Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Daniel Hoyer
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia.,Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Luis de Lecea
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
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8
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A rare genetic variant in the cleavage site of prepro-orexin is associated with idiopathic hypersomnia. NPJ Genom Med 2022; 7:29. [PMID: 35414074 PMCID: PMC9005711 DOI: 10.1038/s41525-022-00298-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/04/2022] [Indexed: 11/08/2022] Open
Abstract
Idiopathic hypersomnia (IH) is a rare, heterogeneous sleep disorder characterized by excessive daytime sleepiness. In contrast to narcolepsy type 1, which is a well-defined type of central disorders of hypersomnolence, the etiology of IH is poorly understood. No susceptibility loci associated with IH have been clearly identified, despite the tendency for familial aggregation of IH. We performed a variation screening of the prepro-orexin/hypocretin and orexin receptors genes and an association study for IH in a Japanese population, with replication (598 patients and 9826 controls). We identified a rare missense variant (g.42184347T>C; p.Lys68Arg; rs537376938) in the cleavage site of prepro-orexin that was associated with IH (minor allele frequency of 1.67% in cases versus 0.32% in controls, P = 2.7 × 10-8, odds ratio = 5.36). Two forms of orexin (orexin-A and -B) are generated from cleavage of one precursor peptide, prepro-orexin. The difference in cleavage efficiency between wild-type (Gly-Lys-Arg; GKR) and mutant (Gly-Arg-Arg; GRR) peptides was examined by assays using proprotein convertase subtilisin/kexin (PCSK) type 1 and PCSK type 2. In both PCSK1 and PCSK2 assays, the cleavage efficiency of the mutant peptide was lower than that of the wild-type peptide. We also confirmed that the prepro-orexin peptides themselves transmitted less signaling through orexin receptors than mature orexin-A and orexin-B peptides. These results indicate that a subgroup of IH is associated with decreased orexin signaling, which is believed to be a hallmark of narcolepsy type 1.
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9
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Marko DM, Finch MS, Mohammad A, MacNeil AJ, Klentrou P, MacPherson REK. Post-Exercise Serum from Humans Influences the Biological Tug of War of APP Processing in Human Neuronal Cells. Am J Physiol Cell Physiol 2022; 322:C614-C623. [PMID: 35196169 DOI: 10.1152/ajpcell.00418.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Neurodegenerative diseases such as Alzheimer's disease (AD) are becoming more prevalent in our aging society. One specific neuropathological hallmark of this disease is the accumulation of amyloid-β (Aβ) peptides, which aggregate to form extra-neuronal plaques. Increased Aβ peptides are often observed well before symptoms of AD develop, highlighting the importance of targeting Aβ producing pathways early on in disease progression. Evidence indicates that exercise has the capacity to reduce Aβ peptide production in the brain however the mechanisms remain unknown. Exercise-induced signaling mediators could be the driving force behind some of the beneficial effects observed in the brain with exercise. The purpose of this study was to examine if post-exercise serum and the factors it contains can alter neuronal APP processing. Human SH-SY5Y neuronal cells were differentiated with retinoic acid for 5 days and treated with 10% pre- or post-exercise serum from humans for 30 minutes. Cells were collected for analysis of acute (30 minutes; n=6) or adaptive (24 hours post-treatment; n=6) responses. There were no statistical differences in ADAM10 and BACE1 mRNA or protein expression with post-exercise serum treatment at either time point. However, there was an increase in the ratio of sAPPa to sAPPβ protein content (p=0.05) after 30 minutes of post-exercise serum treatment. Additionally, 30 minutes of post-exercise serum treatment increased ADAM10 (p=0.01) and BACE1 (p=0.02) activity. These findings suggest that post-exercise serum modulates important enzymes involved in APP processing, pushing the cascade towards the non-amyloidogenic arm.
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Affiliation(s)
- Daniel M Marko
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - Michael S Finch
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - Ahmad Mohammad
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - Adam J MacNeil
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - Panagiota Klentrou
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada.,Department of Kinesiology, Brock University, St. Catharines, ON, Canada
| | - Rebecca E K MacPherson
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada.,Centre for Neuroscience, Brock University, St. Catharines, ON, Canada
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10
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Li S, Zhang R, Hu S, Lai J. Plasma Orexin-A Levels in Patients With Schizophrenia: A Systematic Review and Meta-Analysis. Front Psychiatry 2022; 13:879414. [PMID: 35693955 PMCID: PMC9174516 DOI: 10.3389/fpsyt.2022.879414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Orexins are polypeptides regulating appetite, sleep-wake cycle, and cognition functions, which are commonly disrupted in patients with schizophrenia. Patients with schizophrenia show a decreased connectivity between the prefrontal cortex and midline-anterior thalamus, and orexin can directly activate the axon terminal of cells within the prefrontal cortex and selectively depolarize neurons in the midline intralaminar nuclei of the thalamus. To address the relationship between orexin and schizophrenia, this study performed a meta-analysis on the alteration of plasma orexin-A levels in patients with schizophrenia. METHOD We searched eligible studies in PubMed, Embase, Cochrane, and China National Knowledge Infrastructure (CNKI) from 1998 to September 3, 2021. A total of 8 case-control studies were included in the meta-analyses, providing data on 597 patients with schizophrenia and 370 healthy controls. The Stata version 16.0 software was used to calculate the Hedges's adjusted g with 95% confidence intervals (CI). RESULTS The plasma orexin-A levels were not altered in subjects with schizophrenia (n = 597) when compared to healthy controls (n = 370). Subgroup analyses of gender (male and female vs. only male), country (China vs. other countries), medication (medication vs. non-medication), and the measurement of plasma orexin-A (Enzyme-linked immunosorbent assay vs. radioimmunoassay) revealed heterogeneity ranging from 30.15 to 98.15%, but none showed a significant alteration of plasma orexin-A levels in patients with schizophrenia. Heterogeneity was lower in the other countries and radioimmunoassay subgroup, while other subgroups remained to be highly heterogeneous. No significant evidence of publication bias was found either in Begg's test or the Egger's test. CONCLUSION The present meta-analysis indicated that patients with schizophrenia did not show abnormal plasma levels of orexin-A. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021283455, identifier: CRD42021283455.
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Affiliation(s)
- Shaoli Li
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ruili Zhang
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaohua Hu
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorders' Management in Zhejiang Province, Hangzhou, China.,Brain Research Institute of Zhejiang University, Hangzhou, China.,Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China.,Department of Neurobiology, NHC and CAMS Key Laboratory of Medical Neurobiology, School of Brain Science and Brian Medicine, and MOE Frontier Science Center for Brain Science and Brain-Machine Integration, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianbo Lai
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorders' Management in Zhejiang Province, Hangzhou, China.,Brain Research Institute of Zhejiang University, Hangzhou, China.,Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China.,Department of Neurobiology, NHC and CAMS Key Laboratory of Medical Neurobiology, School of Brain Science and Brian Medicine, and MOE Frontier Science Center for Brain Science and Brain-Machine Integration, Zhejiang University School of Medicine, Hangzhou, China
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11
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Postiglione E, Barateau L, Pizza F, Lopez R, Antelmi E, Rassu AL, Vandi S, Chenini S, Mignot E, Dauvilliers Y, Plazzi G. Narcolepsy with intermediate cerebrospinal level of hypocretin-1. Sleep 2021; 45:6460454. [PMID: 34902030 DOI: 10.1093/sleep/zsab285] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/19/2021] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES To describe the phenotype of narcolepsy with intermediate cerebrospinal hypocretin-1 levels (CSF hcrt-1). METHODS From 1600 consecutive patients with narcolepsy from Bologna and Montpellier sleep centers we selected patients with intermediate CSF hcrt-1 levels (110-200 pg/ml). Clinical, neurophysiological and biological data were contrasted for the presence of cataplexy, HLA-DQB1*06:02, and median CSF hcrt-1 levels (149.34 pg/mL). RESULTS Forty-five (55% males, aged 35 ± 17 years) patients (2.8% of all cases) were included. Thirty-three (73%) were HLA-DQB1*06:02, 29 (64%) reported cataplexy (21, 72.4% with typical features), and 5 (11%) had presumed secondary etiology. Cataplexy was associated with other core narcolepsy symptoms, increased sleep onset REM periods, and nocturnal sleep disruption. Cataplexy and irrepressible daytime sleep were more frequent in HLA DQB1*06:02 positive patients. Lower CSF hcrt-1 levels were associated with hallucinations. CONCLUSION Narcolepsy with intermediate CSF hcrt-1 level is a rare condition with heterogeneous phenotype. HLA DQB1*06:02 and lower CSF hcrt-1 were associated with typical narcolepsy features, calling for future research to distinguish incomplete from secondary narcolepsy forms.
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Affiliation(s)
- Emanuela Postiglione
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Lucie Barateau
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,National Reference Network for Narcolepsy, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, France
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Régis Lopez
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,National Reference Network for Narcolepsy, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, France
| | - Elena Antelmi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Anna-Laura Rassu
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France
| | - Stefano Vandi
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Sofiene Chenini
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,National Reference Network for Narcolepsy, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France
| | - Emmanuel Mignot
- Center for Sleep Sciences and Medicine, Stanford University Medical School, Palo Alto, California
| | - Yves Dauvilliers
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,National Reference Network for Narcolepsy, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, France
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
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12
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Junnarkar G, Allphin C, Profant J, Steininger TL, Chen C, Zomorodi K, Skowronski R, Black J. Development of a lower-sodium oxybate formulation for the treatment of patients with narcolepsy and idiopathic hypersomnia. Expert Opin Drug Discov 2021; 17:109-119. [PMID: 34818123 DOI: 10.1080/17460441.2022.1999226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Sodium oxybate (SXB) is a standard of care for cataplexy, excessive daytime sleepiness, and disrupted nighttime sleep in narcolepsy. At recommended dosages in adults (6-9 g/night), SXB increases daily dietary intake of sodium by 1100-1640 mg. Because excess sodium intake is associated with increased blood pressure and cardiovascular risk, an oxybate formulation containing 92% less sodium than SXB (lower-sodium oxybate; LXB) was developed to provide an alternative oxybate treatment option. In 2020, LXB was approved for treatment of cataplexy or excessive daytime sleepiness in patients 7 years of age and older with narcolepsy, and in 2021, for treatment of idiopathic hypersomnia in adults. AREAS COVERED Development of LXB from initial concept to regulatory approval is described, including formulation development and preclinical and clinical studies. Pharmacokinetic parameters and bioequivalence evaluations from phase 1 clinical trials are detailed. Efficacy and safety results from phase 3 clinical trials of LXB in patients with narcolepsy or idiopathic hypersomnia are presented and discussed. EXPERT OPINION Reducing sodium from high sodium‒containing medications is an important step to offset cardiovascular risks associated with high sodium consumption. The development of LXB exemplifies the importance of a collaborative approach to drug development, with patient needs paramount. PLAIN LANGUAGE SUMMARY Sodium oxybate (Xyrem®) is a medication for people with narcolepsy aged 7 years and older. Xyrem treats symptoms of excessive daytime sleepiness (EDS) or cataplexy (attacks of muscle weakness caused by emotion) in narcolepsy. At the recommended dosages in adults, Xyrem adds a large amount of sodium to daily dietary intake. Too much sodium in the diet is associated with increased blood pressure and risks of damage to the heart and blood vessels. Researchers used calcium, magnesium, and potassium ions in addition to a small amount of sodium to make a new oxybate medication, called Xywav®, that has 92% less sodium than Xyrem. Xywav and Xyrem were similar in laboratory and animal studies. In people, the body absorbs and processes Xywav slightly differently than Xyrem, but Xywav treatment has been shown to work the same to reduce symptoms of cataplexy and EDS in people with narcolepsy and is approved by the US Food and Drug Administration. Another neurological disorder with EDS is called idiopathic hypersomnia. Based on a clinical study, Xywav also reduced EDS and other symptoms in people with idiopathic hypersomnia. Side effects with Xywav are similar to those seen in previous studies with Xyrem.
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Affiliation(s)
- Gunjan Junnarkar
- Pharmaceutical Development and Manufacturing Science, Jazz Pharmaceuticals, Inc., Palo Alto, CA, USA
| | - Clark Allphin
- New Product and Technology Integration, Jazz Pharmaceuticals, Inc., Palo Alto, CA, USA
| | - Judi Profant
- Medical Affairs, Global Molecule Team, Jazz Pharmaceuticals, Inc., Palo Alto, CA, USA
| | - Teresa L Steininger
- Medical Communications, Global Scientific Affairs, Jazz Pharmaceuticals, Inc., Palo Alto, CA, USA
| | - Cuiping Chen
- Neuroscience Clinical Pharmacology, Jazz Pharmaceuticals, Inc., Palo Alto, CA, USA
| | - Katie Zomorodi
- Early Development and Clinical Pharmacology, Jazz Pharmaceuticals, Inc., Palo Alto, CA, USA
| | - Roman Skowronski
- Clinical Development, Jazz Pharmaceuticals, Inc., Palo Alto, CA, USA
| | - Jed Black
- Stanford University Center for Sleep Sciences and Medicine, Palo Alto, CA, USA.,Sleep and CNS Medicine, Jazz Pharmaceuticals, Inc., Palo Alto, CA, USA
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13
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What do I talk about when I talk about measuring CNS orexin-A? Considerations of orexin-A measurements in clinical and preclinical setting. MEDICINE IN DRUG DISCOVERY 2021. [DOI: 10.1016/j.medidd.2021.100101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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14
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Cerebrospinal fluid orexin in Alzheimer's disease: a systematic review and meta-analysis. Sleep Med 2021; 85:230-238. [PMID: 34364094 DOI: 10.1016/j.sleep.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/13/2021] [Accepted: 07/06/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE/BACKGROUND A growing body of evidence suggests that sleep and Alzheimer's disease (AD) have a bi-directional relationship. Emerging research also suggests that orexin, a key neurotransmitter involved in sleep-wake regulation, may be altered in persons with AD, however results have not been consistent across prior studies. This investigation was conducted to both evaluate the aggregate literature to minimize the risk of bias and identify potential factors associated with heterogeneity across studies. METHODS Systematic review identified relevant investigations that compared cerebrospinal fluid orexin in persons with AD and controls. Meta-analysis (random effects model) compared effect size (Hedge's g) for orexin between AD and controls. Meta-regression was additionally performed for key variables of interest to evaluate potential causes of heterogeneity among studies. RESULTS 17 studies were identified that met inclusion/exclusion criteria. Evidence of publication bias was not identified. Non-significant increases in orexin were observed in AD relative to controls, with moderate to large heterogeneity among studies (Hedge's g = 0.20, p = 0.136, I2 = 72.6%). Meta-regression demonstrated both year of publication (β = 0.055, p = 0.020) and effect size for phosphorylated tau in AD versus controls (β = 0.417, p = 0.031) were associated with differences in orexin. CONCLUSIONS Results do not support broad differences in orexin in AD compared to controls, however, evolving diagnostic criteria may have affected findings across studies. Future research that examines orexin in AD over the longitudinal course of the disorder and explores potential links between phosphorylated tau and orexin are indicated.
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15
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Fronczek R, Schinkelshoek M, Shan L, Lammers GJ. The orexin/hypocretin system in neuropsychiatric disorders: Relation to signs and symptoms. HANDBOOK OF CLINICAL NEUROLOGY 2021; 180:343-358. [PMID: 34225940 DOI: 10.1016/b978-0-12-820107-7.00021-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hypocretin-1 and 2 (or orexin A and B) are neuropeptides exclusively produced by a group of neurons in the lateral and dorsomedial hypothalamus that project throughout the brain. In accordance with this, the two different hypocretin receptors are also found throughout the brain. The hypocretin system is mainly involved in sleep-wake regulation, but also in reward mechanisms, food intake and metabolism, autonomic regulation including thermoregulation, and pain. The disorder most strongly linked to the hypocretin system is the primary sleep disorder narcolepsy type 1 caused by a lack of hypocretin signaling, which is most likely due to an autoimmune process targeting the hypocretin-producing neurons. However, the hypocretin system may also be affected, but to a lesser extent and less specifically, in various other neurological disorders. Examples are neurodegenerative diseases such as Alzheimer's, Huntington's and Parkinson's disease, immune-mediated disorders such as multiple sclerosis, neuromyelitis optica, and anti-Ma2 encephalitis, and genetic disorders such as type 1 diabetus mellitus and Prader-Willi Syndrome. A partial hypocretin deficiency may contribute to the sleep features of these disorders.
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Affiliation(s)
- Rolf Fronczek
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands; Sleep Wake Centre SEIN, Heemstede, The Netherlands.
| | - Mink Schinkelshoek
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands; Sleep Wake Centre SEIN, Heemstede, The Netherlands
| | - Ling Shan
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands; Sleep Wake Centre SEIN, Heemstede, The Netherlands; Department Neuropsychiatric Disorders, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
| | - Gert Jan Lammers
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands; Sleep Wake Centre SEIN, Heemstede, The Netherlands
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16
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Ægidius HM, Kruse L, Christensen GL, Lorentzen MP, Jørgensen NR, Moresco M, Pizza F, Plazzi G, Jennum PJ, Kornum BR. Pre-treatment of blood samples reveal normal blood hypocretin/orexin signal in narcolepsy type 1. Brain Commun 2021; 3:fcab050. [PMID: 33977264 PMCID: PMC8100001 DOI: 10.1093/braincomms/fcab050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 12/11/2022] Open
Abstract
The hypocretin/orexin system regulates arousal through central nervous system mechanisms and plays an important role in sleep, wakefulness and energy homeostasis. It is unclear whether hypocretin peptides are also present in blood due to difficulties in measuring reliable and reproducible levels of the peptides in blood samples. Lack of hypocretin signalling causes the sleep disorder narcolepsy type 1, and low concentration of cerebrospinal fluid hypocretin-1/orexin-A peptide is a hallmark of the disease. This measurement has high diagnostic value, but performing a lumbar puncture is not without discomfort and possible complications for the patient. A blood-based test to assess hypocretin-1 deficiency would therefore be of obvious benefit. We here demonstrate that heating plasma or serum samples to 65°C for 30 min at pH 8 significantly increases hypocretin-1 immunoreactivity enabling stable and reproducible measurement of hypocretin-1 in blood samples. Specificity of the signal was verified by high-performance liquid chromatography and by measuring blood samples from mice lacking hypocretin. Unspecific background signal in the assay was high. Using our method, we show that hypocretin-1 immunoreactivity in blood samples from narcolepsy type 1 patients does not differ from the levels detected in control samples. The data presented here suggest that hypocretin-1 is present in the blood stream in the low picograms per millilitres range and that peripheral hypocretin-1 concentrations are unchanged in narcolepsy type 1.
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Affiliation(s)
- Helene M Ægidius
- Department of Neuroscience, University of Copenhagen, 2200 Copenhagen N, Denmark
| | - Lars Kruse
- Department of Clinical Biochemistry, Rigshospitalet, 2600 Glostrup, Denmark
| | | | - Marc P Lorentzen
- Department of Clinical Biochemistry, Rigshospitalet, 2600 Glostrup, Denmark
| | - Niklas R Jørgensen
- Department of Clinical Biochemistry, Rigshospitalet, 2600 Glostrup, Denmark
| | - Monica Moresco
- Istituto delle Scienze Neurologiche, Ospedale Bellaria, IRCCS Bologna, 40139 Bologna, Italy
| | - Fabio Pizza
- Istituto delle Scienze Neurologiche, Ospedale Bellaria, IRCCS Bologna, 40139 Bologna, Italy.,Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
| | - Giuseppe Plazzi
- Istituto delle Scienze Neurologiche, Ospedale Bellaria, IRCCS Bologna, 40139 Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, 41121 Modena, Italy
| | - Poul J Jennum
- Department of Clinical Neurophysiology, Danish Center for Sleep Medicine, Rigshospitalet, 2600 Glostrup, Denmark
| | - Birgitte R Kornum
- Department of Neuroscience, University of Copenhagen, 2200 Copenhagen N, Denmark
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17
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Lindström M, Schinkelshoek M, Tienari PJ, Kukkonen JP, Renkonen R, Fronczek R, Lammers GJ, Itkonen O. Orexin-A measurement in narcolepsy: A stability study and a comparison of LC-MS/MS and immunoassays. Clin Biochem 2021; 90:34-39. [PMID: 33539807 DOI: 10.1016/j.clinbiochem.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Orexin-A and -B are neuropeptides involved in sleep-wake regulation. In human narcolepsy type 1, this cycle is disrupted due to loss of orexin-producing neurons in the hypothalamus. Cerebrospinal fluid (CSF) orexin-A measurement is used in the diagnosis of narcolepsy type 1. Currently available immunoassays may lack specificity for accurate orexin quantification. We developed and validated a liquid chromatography mass spectrometry assay (LC-MS/MS) for CSF orexin-A and B. METHODS We used CSF samples from narcolepsy type 1 (n = 22) and type 2 (n = 6) and non-narcoleptic controls (n = 44). Stable isotope-labeled orexin-A and -B internal standards were added to samples before solid-phase extraction and quantification by LC-MS/MS. The samples were also assayed by commercial radioimmunoassay (RIA, n = 42) and enzymatic immunoassay (EIA, n = 72) kits. Stability of orexins in CSF was studied for 12 months. RESULTS Our assay has a good sensitivity (10 pmol/L = 35 pg/mL) and a wide linear range (35-3500 pg/mL). Added orexin-A and -B were stable in CSF for 12 and 3 months, respectively, when frozen. The median orexin-A concentration in CSF from narcolepsy type 1 patients was <35 pg/mL (range < 35-131 pg/mL), which was lower than that in CSF from control individuals (98 pg/mL, range < 35-424 pg/mL). Orexin-A concentrations determined using our LC-MS/MS assay were five times lower than those measured with a commercial RIA. Orexin-B concentrations were undetectable. CONCLUSIONS Orexin-A concentrations measured by our LC-MS/MS assay were lower in narcolepsy type 1 patients as compared to controls. RIA yielded on average higher concentrations than LC-MS/MS.
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Affiliation(s)
- Mikael Lindström
- HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Mink Schinkelshoek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Sleep-Wake Centre, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Pentti J Tienari
- HUS Neurocenter, Helsinki University Hospital, Helsinki, Finland; Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Finland
| | - Jyrki P Kukkonen
- Department of Pharmacology, Institute of Biomedicine, University of Helsinki, Helsinki, Finland
| | - Risto Renkonen
- HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Transplantation Laboratory, Haartman Institute, University of Helsinki, Helsinki, Finland
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Sleep-Wake Centre, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Gert Jan Lammers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Sleep-Wake Centre, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Outi Itkonen
- HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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18
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Natori Y, Sasaki E, Soeda S, Furukawa S, Azami Y, Tokuda E, Kanbayashi T, Saji S. Risk of immunotherapy-related narcolepsy in genetically predisposed patients: a case report of narcolepsy after administration of pembrolizumab. J Immunother Cancer 2020; 8:jitc-2020-001164. [PMID: 33004543 PMCID: PMC7534705 DOI: 10.1136/jitc-2020-001164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2020] [Indexed: 01/01/2023] Open
Abstract
Background Immune-related adverse events associated with immune checkpoint therapy cause autoimmune disease-like symptoms. People who carry specific genotypes or haplotypes of human leucocyte antigen (HLA) are known to be predisposed to develop autoimmune diseases including narcolepsy. Immunotherapy could be a trigger to develop narcolepsy in predisposing HLA positive patients. Case presentation A 66-year-old woman with stage IVB endometrial carcinosarcoma experienced daytime sleepiness and temporary muscle weakness 14 days after the administration of an immune checkpoint inhibitor, pembrolizumab. These were consistent with the main symptoms of narcolepsy with cataplexy. This patient carried a highly predisposing HLA haplotype for narcolepsy; HLA-DQB1*06:02, DRB1*15:01, DQA1*01:02 and DRB5*01:01:01. A hypocretin-1/orexin-A concentration in the patient’s cerebrospinal fluid was low at 9.6 pg/mL in ELISA, and 155.5 pg/mL in radioimmunoassay that was below the normal level of 200 pg/mL. Therefore, she was diagnosed with narcolepsy tentatively according to the International Classification of Sleep Disorders, third edition diagnostic criteria for narcolepsy. The onset of narcolepsy in the 60s is very rare, and narcoleptic symptoms in our patient were likely to be caused by pembrolizumab. Conclusions This case suggests that treatment with immune checkpoint inhibitors potentially causes narcolepsy in genetically predisposed patients.
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Affiliation(s)
- Yutaka Natori
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Eisaku Sasaki
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Shu Soeda
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima, Japan
| | - Shigenori Furukawa
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima, Japan
| | - Yusuke Azami
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Emi Tokuda
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Takashi Kanbayashi
- International Institute for Integrative Sleep Medicine (WPI-IIIS), University of Tsukuba, Tsukuba, Japan
| | - Shigehira Saji
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
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19
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Murillo-Rodríguez E, Millán-Aldaco D, Palomero-Rivero M, Morales-Lara D, Mechoulam R, Drucker-Colín R. Cannabidiol Partially Blocks the Excessive Sleepiness in Hypocretindeficient Rats: Preliminary Data. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 18:705-712. [PMID: 31642794 DOI: 10.2174/1871527318666191021143300] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/05/2019] [Accepted: 09/13/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Excessive daytime sleepiness and cataplexy are among the symptoms of narcolepsy, a sleep disorder caused by the loss of hypocretin/orexin (HCRT/OX) neurons placed into the Hypothalamus (LH). Several treatments for managing narcolepsy include diverse drugs to induce alertness, such as antidepressants, amphetamine, or modafinil, etc. Recent evidence has shown that cannabidiol (CBD), a non-psychotropic derived from Cannabis sativa, shows positive therapeutic effects in neurodegenerative disorders, including Parkinson´s disease. Furthermore, CBD provokes alertness and enhances wake-related neurochemicals in laboratory animals. Thus, it is plausible to hypothesize that excessive somnolence observed in narcolepsy might be blocked by CBD. OBJECTIVE Here, we determined whether the systemic injection of CBD (5mg/kg, i.p.) would block the excessive sleepiness in a narcoleptic model. METHODS To test this idea, the neurotoxin hypocretin-2-saporin (HCRT2/SAP) was bilaterally injected into the LH of rats to eliminate HCRT leading to the establishment of narcoleptic-like behavior. Since excessive somnolence in HCRT2/SAP lesioned rats has been observed during the lights-off period, CBD was administered at the beginning of the dark phase. RESULTS Hourly analysis of sleep data showed that CBD blocked the sleepiness during the lights-off period across 7h post-injection in lesioned rats. CONCLUSION Taking together, these preliminary findings suggest that CBD might prevent sleepiness in narcolepsy.
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Affiliation(s)
- Eric Murillo-Rodríguez
- Laboratorio de Neurociencias Moleculares e Integrativas, Escuela de Medicina, División Ciencias de la Salud, Universidad Anáhuac Mayab, Mérida, Yucatán, Mexico.,Intercontinental Neuroscience Research Group, Merida, Yucatán, Mexico
| | - Diana Millán-Aldaco
- Depto. de Neurociencia Cognitiva, División de Neurociencias, Instituto de Fisiología Celular. Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | - Marcela Palomero-Rivero
- Depto. de Neuropatología Molecular, División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | - Daniela Morales-Lara
- Laboratorio de Neurociencias Moleculares e Integrativas, Escuela de Medicina, División Ciencias de la Salud, Universidad Anáhuac Mayab, Mérida, Yucatán, Mexico.,Intercontinental Neuroscience Research Group, Merida, Yucatán, Mexico
| | - Raphael Mechoulam
- Institute for Drug Research, Medical Faculty, Hebrew University, Jerusalem, Israel
| | - René Drucker-Colín
- Depto. de Neuropatología Molecular, División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
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20
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Abstract
PURPOSE OF REVIEW To review sleep complaints reported in patients with autoimmune encephalitis, explore the relationship between sleep disturbances and subtypes of autoimmune encephalitis, and leverage knowledge concerning antibody-antigen specificity to inform the receptors, structures, and disseminated neural networks that contribute to sleep function in health and disease. RECENT FINDINGS Autoimmune encephalitis is an inflammatory brain disorder characterized by the subacute onset of psychiatric symptoms, cognitive impairment, and focal neurologic deficits or seizures. Sleep disturbances are detected in a majority of patients systematically screened for sleep complaints, may be the presenting symptom in patients with autoimmune encephalitis, and may compromise recovery in patients with autoimmune encephalitis. Early recognition of specific sleep disturbances in patients with subacute changes in behavior or cognition may support the diagnosis of autoimmune encephalitis. Similarly, recognition and treatment of sleep dysfunction in patients with known autoimmune encephalitis may speed recovery and improve long-term outcomes.
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Affiliation(s)
- Margaret S Blattner
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, USA.
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21
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Romigi A, Caccamo M, Vitrani G, Testa F, Nicoletta C, Sarno AC, Di Gioia B, Centonze D. A false alarm of narcolepsy: obstructive sleep apnea masquerading as narcolepsy and vice-versa: two further controversial cases. Sleep Breath 2020; 25:367-370. [PMID: 32297143 DOI: 10.1007/s11325-020-02070-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/02/2020] [Accepted: 03/23/2020] [Indexed: 12/01/2022]
Affiliation(s)
- A Romigi
- IRCCS Neuromed Sleep Medicine Center, Via Atinense 18, Pozzilli (IS), Italy.
| | - M Caccamo
- IRCCS Neuromed Sleep Medicine Center, Via Atinense 18, Pozzilli (IS), Italy
| | - G Vitrani
- IRCCS Neuromed Sleep Medicine Center, Via Atinense 18, Pozzilli (IS), Italy
| | - F Testa
- IRCCS Neuromed Sleep Medicine Center, Via Atinense 18, Pozzilli (IS), Italy
| | - C Nicoletta
- IRCCS Neuromed Sleep Medicine Center, Via Atinense 18, Pozzilli (IS), Italy
| | - A C Sarno
- IRCCS Neuromed Sleep Medicine Center, Via Atinense 18, Pozzilli (IS), Italy
| | - B Di Gioia
- IRCCS Neuromed Sleep Medicine Center, Via Atinense 18, Pozzilli (IS), Italy
| | - D Centonze
- IRCCS Neuromed Sleep Medicine Center, Via Atinense 18, Pozzilli (IS), Italy
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22
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Ravel JM, Mignot EJM. [Narcolepsy: From the discovery of a wake promoting peptide to autoimmune T cell biology and molecular mimicry with flu epitopes]. Biol Aujourdhui 2019; 213:87-108. [PMID: 31829930 DOI: 10.1051/jbio/2019026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Indexed: 11/14/2022]
Abstract
Narcolepsy-cataplexy was first described in the late 19th century in Germany and France. Prevalence was established to be 0.05 % and a canine model was discovered in the 1970s. In 1983, a Japanese study found that all patients carried HLA-DR2, suggesting autoimmunity as the cause of the disease. Studies in the canine model established that dopaminergic stimulation underlies anti-narcoleptic action of psychostimulants, while antidepressants were found to suppress cataplexy through adrenergic reuptake inhibition. No HLA association was found in canines. A linkage study initiated in 1988 revealed in hypocretin (orexin) receptor two mutations as the cause of canine narcolepsy in 1999. In 1992, studies on African Americans showed that DQ0602 was a better marker than DR2 across all ethnic groups. In 2000, hypocretin-1/orexin A levels were measured in the cerebrospinal fluid (CSF) and found to be undetectable in most patients, establishing hypocretin deficiency as the cause of narcolepsy. Decreased CSF hypocretin-1 was then found to be secondary to the loss of the 70,000 neurons producing hypocretin in the hypothalamus, suggesting immune destruction of these cells as the cause of the disease. Additional genetic studies, notably genome wide associations (GWAS), found multiple genetic predisposing factors for narcolepsy. These were almost all involved in other autoimmune diseases, although a strong and unique association with T cell receptor (TCR) alpha and beta loci were observed. Nonetheless, all attempts to demonstrate presence of autoantibodies against hypocretin cells in narcolepsy failed, and the presumed autoimmune cause remained unproven. In 2009, association with strep throat infections were found, and narcolepsy onsets were found to occur more frequently in spring and summer, suggesting upper away infections as triggers. Following reports that narcolepsy cases were triggered by vaccinations and infections against influenza A 2009 pH1N1, a new pandemic strain that erupted in 2009, molecular mimicry with influenza A virus was suggested in 2010. This hypothesis was later confirmed by peptide screening showing higher activity of CD4+ T cell reactivity to a specific post-translationally amidated segment of hypocretin (HCRT-NH2) and cross-reactivity of specific TCRs with a pH1N1-specific segment of hemagglutinin that shares homology with HCRT-NH2. Strikingly, the most frequent TCR recognizing these antigens was found to carry sequences containing TRAJ24 or TRVB4-2, segments modulated by narcolepsy-associated genetic polymorphisms. Cross-reactive CD4+ T cells with these cross-reactive TCRs likely subsequently recruit CD8+ T cells that are then involved in hypocretin cell destruction. Additional flu mimics are also likely to be discovered since narcolepsy existed prior to 2009. The work that has been conducted over the years on narcolepsy offers a unique perspective on the conduct of research on the etiopathogeny of a specific disease.
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Affiliation(s)
- Jean-Marie Ravel
- Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Medicine, Stanford University, 3615 Porter Drive, Palo Alto, CA, USA
| | - Emmanuel J M Mignot
- Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Medicine, Stanford University, 3615 Porter Drive, Palo Alto, CA, USA
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Narcolepsy — clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol 2019; 15:519-539. [DOI: 10.1038/s41582-019-0226-9] [Citation(s) in RCA: 204] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2019] [Indexed: 12/15/2022]
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24
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Bårdsen K, Gjerstad MD, Partinen M, Kvivik I, Tjensvoll AB, Ruoff P, Omdal R, Brede C. Considerably Lower Levels of Hypocretin-1 in Cerebrospinal Fluid Is Revealed by a Novel Mass Spectrometry Method Compared with Standard Radioimmunoassay. Anal Chem 2019; 91:9323-9329. [DOI: 10.1021/acs.analchem.9b02710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Kjetil Bårdsen
- Research Department, Stavanger University Hospital, Stavanger, Norway
- Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, Stavanger, Norway
| | - Michaela D. Gjerstad
- The Norwegian Centre for Movement Disorders, Stavanger University Hospital, Stavanger, Norway
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Markku Partinen
- Helsinki Sleep Clinic, Vitalmed Research Centre, Helsinki, Finland
| | - Ingeborg Kvivik
- Research Department, Stavanger University Hospital, Stavanger, Norway
| | | | - Peter Ruoff
- Centre for Organelle Research (CORE), Faculty of Science and Technology, University of Stavanger, Stavanger, Norway
| | - Roald Omdal
- Clinical Immunology Unit, Department of Internal Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Cato Brede
- Department of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
- Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, Stavanger, Norway
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