Confirmed clinical efficacy of Actovegin in elderly patients with organic brain syndrome

Analysis of neuroprotective medication in patients with neurocognitive disorders: The efficacy and tolerability of highly purified animal tissues extracts

"Neurocognitive disorders are extremely invalidating psychiatric disorders with chronic courses and significant negative impacts over all areas of cognitive functioning and behavioral activity. Although extensive research on these progressive neurodegenerative disorders has been conducted, pathogenetic treatments with long-term significant benefits are yet controversial. From a clinical perspective, there is an acute need to find therapeutic strategies that could delay cognitive impairment in patients diagnosed with Alzheimer’s disease (AD), vascular dementia (VaD), Lewy body dementia (LBD), etc. Also, slowing the transition from mild cognitive impairment (MCI) to clinically significant AD is another important clinical aspect, with a major impact on the patient’s daily functioning, quality of life, and caregivers’ burden. Acetylcholinesterase inhibitors (AChEI) are still the first line of treatment in AD patients, and they are also administered in the case of VaD or Parkinson’s dementia. Various nootropics have been studied in this population, as add-on agents. Highly purified animal tissue extracts (HPATE) are administered in patients with neurocognitive disorders due to their neurotrophic properties, but many questions remain unanswered regarding their pharmacodynamic characteristics. These extracts may be added to AChEI to enhance their pro-cognitive effect, but evidence to support the superior efficacity of this association versus AChEI monotherapy is mainly derived from low-to-medium quality clinical trials. In conclusion, HPATE may be a useful add-on to first-line pro-cognitive agents in AD and VaD, but larger trials with better methodology are needed. In particular cases, however, HPATE may be of significant interest for patients with mild-to-moderate AD, based on results from clinical practice."

The role of the new coronavirus infection (COVID-19) in the progression and development of cerebrovascular diseases. A competent choice of pathogenic treatment is the key to success in treatment and prevention. An expert’s view from the ‘red zone’

COVID-19 worsens the course of cerebrovascular diseases (CVD), including chronic cerebral ischaemia (CCI). The Actovegin drug, which has long been widely used in CCI treatment, has an antioxidant and endothelium protective effect. It makes sense to study the effect of Actovegin therapy on the clinical manifestations of CCI in patients with a recent experience of COVID-19.

Objective: to evaluate Actovegin efficacy in the treatment of CCI in patients with a recent experience of COVID-19.

Patients and methods. The study included 440 patients (234 female; 206 male) with a recent experience of COVID-19, suffering from CCI, their average age being 67.8 years (from 54 to 85 years). All patients were broken down into two groups of 220 people (the patients in Group 1 were administrated Actovegin, the ones in Group 2 – were not). All patients were followed up for 90 days; their condition was assessed by the severity of clinical manifestations of CCI, using special scales and questionnaires.

Results and discussion. After 90 days of follow-up, the frequency of complaints of cognitive impairment, sleep disorder, dizziness, fatigue, emotional disorders, and headache in Group 1 was significantly lower than in Group 2 (p<0.05). According to Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), Multidimensional Fatigue Inventory (MFI-20), and Spiegel Sleep Questionnaire (SSQ), the average indicators improved significantly more in Group 1 than in Group 2 (p<0.05). The absence of quality of life impairment and their minimal severity were observed in Group 1 in 77.9%; in Group 2 – in 33.7% (p<0.001). Statistically significant differences between the groups of patients were also observed in relation to emotional state recovery according to the Wakefield Questionnaire and the Spielberger State Trait Anxiety inventory.

Conclusion. The observational study demonstrated the efficacy of Actovegin in the treatment of main clinical manifestations of CCI in patients with recent COVID-19 experience.

The efficacy and safety of animal-derived nootropics in cognitive disorders: Systematic review and meta-analysis

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Animal-derived nootropics may have potential in treating cognitive disorders, especially vascular cognitive impairment.

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Despite widespread use, there are few randomized controlled trials on animal derived nootropics for cognitive disorders.

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Our review suggested modest beneficial effects of these nootropics, but the strength of supporting evidence was limited.

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The clinical significance of the reviewed nootropics in treating vascular cognitive impairment remains unclear.

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The findings of this review indicate promising evidence to justify further large-scale randomized controlled trials.

Background

The animal-derived nootropics, Cerebrolysin, Actovegin and Cortexin, may have potential in treating neurocognitive disorders. Although these drugs have international usage, reports on their efficacy have been conflicting. These agents have been suggested for all dementia types, but may have particular utility in vascular cognitive impairment (VCI). We used systematic review and meta-analyses to summarize evidence of efficacy in all cause dementia, with a subgroup analysis restricted to VCI.

Methods

We searched multidisciplinary, electronic databases from inception to August 2020. We assessed risk of bias using the Cochrane tool and framed results using GRADE criteria. We used random effects models to create summary estimates. Our primary outcome was change in cognition based on any quantitative cognitive assessment scale using standardized mean difference (SMD). We assessed various secondary efficacy outcomes and a safety outcome of serious adverse events. We performed subgroup analyses limited to VCI.

Results

Summary estimates suggested Cerebrolysin was potentially beneficial in improving cognition (8 trials,793 participants, SMD:-0.16, 95%CI:-0.30 to -0.03) and global function (4 trials,479 participants, OR:2.64, 95%CI:1.17 to 5.98) in the short term. There was no difference in incidence of serious adverse events (6 trials,1014 participants, RR:0.96, 95%CI:0.78 to 1.18). In our VCI subgroup, results were similar to the main analysis, with a beneficial effect on cognition (SMD:-0.22, 95%CI:-0.42 to -0.03) and clinical global impression (OR 2.99, 95%CI:1.02 to 8.73). The limited number of eligible studies for Actovegin (n = 2 trials,563 participants) and Cortexin, (n = 1 trial,80 participants) precluded meta-analyses but data suggested potential efficacy and no safety concerns. Across all included studies, risk of bias was moderate to high, there was imprecision, and certainty of evidence was considered low to very low.

Conclusion

Although published data suggest potential benefits and relative safety of animal derived nootropics, the supporting evidence is weak. The size of the effects demonstrated were modest and probably less than would be considered clinically relevant.

Poststroke cognitive impairment

Cognitive impairment (CI) is one of the leading causes of disability after stroke; CI is observed in more than half of patients and reaches a pronounced degree (of dementia) in every three to five patients. CI in poststroke patients is often caused not only by focal vascular lesions of the brain, but also by the presence of concomitant vascular and neurodegenerative diseases. The treatment and prevention of progressive CI are based on stroke prevention, non-drug and drug methods to improve cognitive functions. Blood pressure normalization during antihypertensive therapy is most effective in preventing the progression of CI in stroke patients. The use of Actovegin in patients with CI after stroke is discussed. The results of the author's own 5-year follow-up of 350 patients with stroke are presented.

Animal-derived medicinal products in Russia: Current nomenclature and specific aspects of quality control

ETHNOPHARMACOLOGICAL RELEVANCE

Animal-derived medicinal products (ADMP) had been extensively used in Russia and became a part of officinal medicine in 1778.

AIM OF THE STUDY

The aim of the current review was to analyse the ADMPs authorised in the Russian Federation and to identify specific aspects of quality evaluation of these medicinal products.

MATERIALS AND METHODS

Information of ADMPs was extracted from the online State Register of Medicinal Products of the Russian Federation. At the next stage, we systematically searched library catalogues, E-library.ru, Medline/PubMed, Scopus, Web of Science and Google Scholar databases to find data related to ADMP quality evaluation, clinically proven efficacy and safety.

RESULTS

For classification of ADMP, we propose an approach based on the raw material used: ADMPs derived from marine organisms, ADMPs from cattle and pigs and ADMPs from other terrestrial animals. The majority of ADMPs authorised in Russia are produced by local manufacturers. ADMPs are available in dosage forms of solution for parenteral administration (35% of all products) and lyophilisates for parenteral use (19%), tablets and capsules (17% and 11%, respectively), ointments (5%) and powders (3%). ADMPs belong to the following pharmacotherapeutic groups: medicines for tissue regeneration and repair stimulators (30%), digestive enzyme products (22%), anticoagulants (17%), proteolytic agents (6%) and medicines for the treatment of chronic prostatitis (5%). The most important approaches to standardisation of ADMPs are implementation of modern requirements for registration dossiers, development of risk-oriented approaches for evaluation of impurities, elaboration of advanced instrumental and in vitro test methods capable of replacing in vivo methods and harmonisation of the potency units used for standardisation.

CONCLUSIONS

The key features of ADMPs that help them retain their leading position in the pharmaceutical market are as follows: (i) their unique composition usually represented by a complex of biologically active substances; (ii) a high degree of affinity of the active ingredient of an ADMP to the human body and (iii) proved safety and clinical efficiency. Variability in the quality of raw ingredients, epidemiological situation and other conditions pose additional challenges for the development of ADMPs and for the standardisation.

Actovegin, a non-prohibited drug increases oxidative capacity in human skeletal muscle

Actovegin, a deproteinized haemodialysate of calf blood, is suggested to have ergogenic properties, but this potential effect has never been investigated in human skeletal muscle. To investigate this purported ergogenic effect, we measured the mitochondrial respiratory capacity in permeabilized human skeletal muscle fibres acutely exposed to Actovegin in a low and in a high dose. We found that Actovegin, in the presence of complex I-linked substrates increased the oxidative phosphorylation (OXPHOS) capacity significantly in a concentration-dependent manner (19 ± 3, 31 ± 4 and 45 ± 4 pmol/mg/s). Maximal OXPHOS capacity with complex I and II-linked substrate was increased when the fibres were exposed to the high dose of Actovegin (62 ± 6 and 77 ± 6 pmol/mg/s) (p < .05). The respiratory capacity of the electron transfer system as well as Vmax and Km were also increased in a concentration-dependent manner after Actovegin exposure (70 ± 6, 79 ± 6 and 88 ± 7 pmol/mg/s; 13 ± 2, 25 ± 3 and 37 ± 4 pmol/mg/s; 0.08 ± 0.02, 0.21 ± 0.03 and 0.36 ± 0.03 mM, respectively) (p < .05). In summary, we report for the first time that Actovegin has a marked effect on mitochondrial oxidative function in human skeletal muscle. Mitochondrial adaptations like this are also seen after a training program in human subjects. Whether this improvement translates into an ergogenic effect in athletes and thus reiterates the need to include Actovegin on the World Anti-Doping Agency's active list remains to be investigated.

Treatment with Actovegin improves spatial learning and memory in rats following transient forebrain ischaemia

This study aimed to investigate whether Actovegin, which is a deproteinized ultrafiltrate derived from calf blood, demonstrates neuroprotective effects in a rat model of transient global cerebral ischaemia. Forty Sprague Dawley rats were subjected to four-vessel occlusion to induce transient global cerebral ischaemia followed by either saline or Actovegin treatment. Sham operations were performed on 15 rats. Actovegin (200 mg/kg) or saline was administered 6 hrs after carotid artery occlusion and then daily until Day 40. Learning and memory were evaluated using the Morris water maze test over two different 5-day periods, and grip strength testing was also performed to control for potential motor impairments. Rat brains were harvested for histological analysis on Day 68. In comparison to controls, Actovegin-treated rats exhibited a decreased latency to reach the hidden platform on the second learning trial of water maze testing (46.82 ± 6.18 versus 27.64 ± 4.53 sec., P < 0.05; 38.3 ± 8.23 versus 13.37 ± 2.73 sec., P < 0.01 for the first and second 5-day testing periods, respectively). In addition, Actovegin-treated rats spent more time in the platform quadrant than saline-treated rats during memory trials (P < 0.05). No differences in grip strength were detected. Histological analyses demonstrated increased cell survival in the CA1 region of the hippocampus following Actovegin treatment (left hemisphere, 166 ± 50 versus 332 ± 27 cells, P < 0.05; right hemisphere, 170 ± 45 versus 307 ± 28 cells, P < 0.05, in saline- versus Actovegin-treated rats, respectively). In rats, Actovegin treatment improves spatial learning and memory following cerebral ischaemia, which may be related to hippocampal CA1 neuroprotection.

A Randomised, Double-Blind, Placebo-Controlled Trial of Actovegin in Patients with Post-Stroke Cognitive Impairment: ARTEMIDA Study Design

Background

No drug treatment to date has shown convincing clinical evidence of restoring cognitive function or preventing further decline after stroke. The ongoing ARTEMIDA study will evaluate the efficacy and safety of Actovegin for the symptomatic treatment of post-stroke cognitive impairment (PSCI) and will explore whether Actovegin has any disease-modifying effect by assessing whether any changes are sustained after treatment.

Design

ARTEMIDA is a 12-month, multicentre trial in patients (planned a total of 500, now recruited) with cognitive impairment following ischaemic stroke. The study consists of a baseline screening (≤7 days after stroke), after which eligible patients are randomised to Actovegin (2,000 mg/day for up to 20 intravenous infusions followed by 1,200 mg/day orally) or placebo for a 6-month double-blind treatment period. Patients will be followed up for a further 6 months, during which time they will be treated in accordance with standard clinical practice. The primary study endpoint is change from baseline in the Alzheimer's Disease Assessment Scale, cognitive subscale, extended version. Secondary outcomes include: Montreal Cognitive Assessment; dementia diagnosis (ICD-10); National Institutes of Health Stroke Scale; Barthel Index; EQ-5D; Beck Depression Inventory, version II, and safety.

Conclusion

There is a clear need for effective treatments for PSCI. ARTEMIDA should provide important insights into the use of a novel drug therapy for PSCI.

Neuroprotection in vascular dementia: a future path

The burden of cognitive disorders is likely to increase over the coming years due to both increased longevity and altered risk factor patterns, arising from changes in lifestyle, healthcare and society. Vascular dementia with its underlying heterogeneous pathology, is a challenge for clinicians, and is frequently further aggravated by overlap with other neurodegenerative processes. Current Alzheimer's disease drugs have had limited clinical efficacy in treating vascular dementia and none have been approved by major regulatory authorities specifically for this disease. Moving forward, a valid choice may be a multimodal therapy, as has already been successfully proven in Alzheimer's disease. Actovegin, a hemodialysate derived from calf blood, has been shown to have effects on a variety of cellular processes and a recent experimental study has revealed its neuroprotective mechanisms of action. These data, coupled with positive results from clinical trials in mixed dementia populations, have served as a foundation for the design of a new trial investigating the efficacy and disease-modifying effects of Actovegin in post-stroke cognitive impairment.

Neuroprotective and anti-oxidative effects of the hemodialysate actovegin on primary rat neurons in vitro

The recently described therapeutic benefits of the hemodialysate actovegin on neuropathic symptoms in diabetic patients with symptomatic polyneuropathy suggest a neuroprotective activity of the drug. To elucidate the possible cellular mechanism of the pharmacological effects of actovegin, we investigated its effects on cultured primary rat neurons in vitro. Primary neurons were cultured for up to 10 days in the presence of increasing doses of actovegin (0.3–1,000 mg/l). Total cell number, dendrite length and the number of excitatory synapses, i.e., the amount of the synaptic V-Glut1 protein, were measured by immunocytochemistry followed by fluorescence microscopy. The apoptotic level in neurons after induction of apoptosis by amyloid peptide Aβ_25–35 was assessed by the level of activated caspase-3. In addition, the capability of the neurons to diminish oxidative stress was assessed by measuring the cellular level of reactive oxygen species ROS in the presence of actovegin. Actovegin treatment yielded an increased maintenance of neuronal cells and total number of synapses and could lower the level of activated caspase-3 in a dose-dependent manner. Dendrite lengths were not significantly affected. In addition, actovegin reduced the cellular level of ROS in cultured neurons. The cellular effects observed suggest neuroprotective and anti-oxidative effects of the drug Actovegin^®, which could at least partially explain its therapeutic benefits.

Treatment of symptomatic polyneuropathy with actovegin in type 2 diabetic patients

OBJECTIVE To evaluate the efficacy and safety of actovegin in patients with diabetic polyneuropathy. RESEARCH DESIGN AND METHODS In this multicenter, randomized, double-blind trial, 567 patients with type 2 diabetes received 20 intravenous infusions of actovegin (2,000 mg/day) (n = 281) or placebo (n = 286) once daily followed by three tablets of actovegin (1,800 mg/day) or placebo three times daily for 140 days. Total symptom score (TSS) of the lower limbs and vibration perception threshold (VPT) were used as coprimary outcome measures, computed as the area under the curve (AUC) from repeated scores and divided by duration of exposure. Secondary end points included individual TSS symptoms, neuropathy impairment score of the lower limbs (NIS-LL), and quality of life (short form [SF]-36). RESULTS TSS was significantly improved during actovegin treatment compared with placebo, as assessed by AUC (-0.56 points [95% CI -0.85 to -0.27]; P = 0.0003), and from baseline to 160 days (-0.86 points [-1.22 to -0.50]; P < 0.0001). VPT (five sites per foot) decreased by 3% (95% CI 0-6; P = 0.084) with actovegin than placebo, as assessed by AUC, and by 5% (1-9; P = 0.017) after 160 days. NIS-LL sensory function, as assessed by AUC, was significantly improved with actovegin versus placebo (-0.25 [95% CI -0.46 to -0.04]; P = 0.021), as was the SF-36 mental health domain. There were no differences in the incidence of adverse events between the groups. CONCLUSIONS Sequential intravenous and oral actovegin treatment over 160 days improved neuropathic symptoms, VPT, sensory function, and quality of life in type 2 diabetic patients with symptomatic polyneuropathy.

Peptidomics: a logical sequel to proteomics

Rapid progress of separation techniques as well as methods of structural analysis provided conditions in the past decade for total screening of complex biologic mixtures for any given class of biomolecules. The present review updates the reader with the modern state of peptidomics, a chapter of chemical biology that deals with structure and biologic properties of sets of peptides present in biologic tissues, cells or fluids. Scope and limitations of currently employed experimental techniques are considered and the main results are outlined. Considerable attention will be afforded to the biologic role of peptides formed in vivo by proteolysis of nonspecialized precursor proteins with other well-defined functions. In conclusion, the connection is discussed between peptidomics and the much more mature and still closely related field of proteomics.

Antidepressants for treating depression in dementia

The use of antidepressants for patients with dementia accompanied by depressive symptoms is widespread, but their clinical efficacy is uncertain. Many of the individual trials of antidepressants have been too small to provide precise estimates of the moderate benefits that might realistically be expected. Combining the information from all appropriate trials may provide a better estimate of the likely effects of treatment.Objectives To determine whether antidepressants are clinically effective and acceptable for the treatment of patients with depression and also dementia.Search methods The CDCIG Specialized Register was last searched on 27 April 2005. This register contains records from major health care databases and many ongoing trials databases and is updated regularly.Medical information departments of pharmaceutical companies were asked to search their databases for any relevant clinical trials. Where necessary authors of trials were approached with requests for additional information.Selection criteria All relevant unconfounded, double-blind, randomized trials comparing any antidepressant drug with placebo, for patients diagnosed as having dementia and depression, according to established criteria.Data collection and analysis Two reviewers extracted data independently and settled any differences by agreement.Main results There were seven included studies with a total of 1140 subjects of which 769 met inclusion criteria. Four included studies reported sufficiently detailed results to enter into meta-analyses, with a total of 137 subjects. Two of these studies investigated the properties of drugs not commonly used in this population with only two studies (Petracca 2001 and Lyketsos 2003) using the more common selective serotonin reuptake inhibitors (SSRIs). Lyketsos 2003 produced two significant differences in favour of treatment in the Cornell Scale for Depression in Dementia (CSDD) at 12 weeks and in the psychiatrists' global rating. However, the CSDD was not used in any of the other studies and no statistical differences were found with the other measures used in the meta-analysis. The meta-analysis of the number of patients suffering at least one adverse event, one event of the nervous system, one event of the gastrointestinal system and one event of dry mouth at 6 to 12 weeks showed a significant difference in favour of placebo. There were no other significant results.Authors' conclusions Available evidence offers weak support to the contention that antidepressants are effective for patients with depression and dementia.However, only four studies are included in the meta-analysis relating to efficacy, and sample sizes are small.Moreover, only two included studies investigated the properties of the more commonly used SSRIs and no studies investigated the properties of newer classes of antidepressants (e.g. selective noradrenergic reuptake inhibitors). This review draws attention to the paucity of research and evidence in this area.