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Tobinick E, Ucci D, Bermudo K, Asseraf S. Perispinal etanercept stroke trial design: PESTO and beyond. Expert Opin Biol Ther 2024:1-14. [PMID: 39177653 DOI: 10.1080/14712598.2024.2390636] [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: 07/23/2024] [Accepted: 08/06/2024] [Indexed: 08/24/2024]
Abstract
INTRODUCTION Perispinal etanercept (PSE) is an innovative treatment designed to improve stroke recovery by addressing chronic post-stroke neuroinflammation. Basic science evidence, randomized clinical trial (RCT) evidence and 14 years of favorable clinical experience support the use of PSE to treat chronic stroke. This article provides guidance for the design of future PSE RCTs in accordance with current FDA recommendations. AREAS COVERED Scientific background and essential elements of PSE RCT design. EXPERT OPINION Intimate familiarity with PSE, its novel method of drug delivery, and the characteristics of ideal enriched study populations are necessary for those designing future PSE stroke trials. The design elements needed to enable a PSE RCT to generate valid results include a suitable research question; a homogeneous study population selected using a prospective enrichment strategy; a primary outcome measure responsive to the neurological improvements that result from PSE; trialists with expertise in perispinal delivery; optimal etanercept dosing; and steps taken to minimize the number of placebo responders. RCTs failing to incorporate these elements, such as the PESTO trial, are incapable of reaching reliable conclusions regarding PSE efficacy. SF-36 has not been validated in PSE trials and is unsuitable for use as a primary outcome measure in PSE RCTs.
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Affiliation(s)
| | - Danielle Ucci
- Institute of Neurological Recovery, Boca Raton, FL, USA
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Arfaei R, Mikaeili N, Daj F, Boroumand A, Kheyri A, Yaraghi P, Shirzad Z, Keshavarz M, Hassanshahi G, Jafarzadeh A, Shahrokhi VM, Khorramdelazad H. Decoding the role of the CCL2/CCR2 axis in Alzheimer's disease and innovating therapeutic approaches: Keeping All options open. Int Immunopharmacol 2024; 135:112328. [PMID: 38796962 DOI: 10.1016/j.intimp.2024.112328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/11/2024] [Accepted: 05/20/2024] [Indexed: 05/29/2024]
Abstract
Alzheimer's disease (AD), as a neurodegenerative disorder, distresses the elderly in large numbers and is characterized by β-amyloid (Aβ) accumulation, elevated tau protein levels, and chronic inflammation. The brain's immune system is aided by microglia and astrocytes, which produce chemokines and cytokines. Nevertheless, dysregulated expression can cause hyperinflammation and lead to neurodegeneration. CCL2/CCR2 chemokines are implicated in neurodegenerative diseases exacerbating. Inflicting damage on nerves and central nervous system (CNS) cells is the function of this axis, which recruits and migrates immune cells, including monocytes and macrophages. It has been shown that targeting the CCL2/CCR2 axis may be a therapeutic option for inflammatory diseases. Using the current knowledge about the involvement of the CCL2/CCR2 axis in the immunopathogenesis of AD, this comprehensive review synthesizes existing information. It also explores potential therapeutic options, including modulation of the CCL2/CCR2 axis as a possible strategy in AD.
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Affiliation(s)
- Reyhaneh Arfaei
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Narges Mikaeili
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Fatemeh Daj
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Armin Boroumand
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Abbas Kheyri
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Pegah Yaraghi
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Zahra Shirzad
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Mohammad Keshavarz
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Gholamhossein Hassanshahi
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Abdollah Jafarzadeh
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Vahid Mohammadi Shahrokhi
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Hossein Khorramdelazad
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
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Plantone D, Pardini M, Righi D, Manco C, Colombo BM, De Stefano N. The Role of TNF-α in Alzheimer's Disease: A Narrative Review. Cells 2023; 13:54. [PMID: 38201258 PMCID: PMC10778385 DOI: 10.3390/cells13010054] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/22/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
This review analyzes the role of TNF-α and its increase in biological fluids in mild cognitive impairment, and Alzheimer's disease (AD). The potential inhibition of TNF-α with pharmacological strategies paves the way for preventing AD and improving cognitive function in people at risk for dementia. We conducted a narrative review to characterize the evidence in relation to the involvement of TNF-α in AD and its possible therapeutic inhibition. Several studies report that patients with RA and systemic inflammatory diseases treated with TNF-α blocking agents reduce the probability of emerging dementia compared with the general population. Animal model studies also showed interesting results and are discussed. An increasing amount of basic scientific data and clinical studies underscore the importance of inflammatory processes and subsequent glial activation in the pathogenesis of AD. TNF-α targeted therapy is a biologically plausible approach for cognition preservation and further trials are necessary to investigate the potential benefits of therapy in populations at risk of developing AD.
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Affiliation(s)
- Domenico Plantone
- Department of Medicine, Surgery and Neuroscience, University of Siena, Viale Bracci 2, 53100 Siena, Italy; (D.R.); (C.M.); (N.D.S.)
| | - Matteo Pardini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, L.go P. Daneo 3, 16132 Genova, Italy;
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genova, Italy;
| | - Delia Righi
- Department of Medicine, Surgery and Neuroscience, University of Siena, Viale Bracci 2, 53100 Siena, Italy; (D.R.); (C.M.); (N.D.S.)
| | - Carlo Manco
- Department of Medicine, Surgery and Neuroscience, University of Siena, Viale Bracci 2, 53100 Siena, Italy; (D.R.); (C.M.); (N.D.S.)
| | - Barbara Maria Colombo
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genova, Italy;
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Viale Bracci 2, 53100 Siena, Italy; (D.R.); (C.M.); (N.D.S.)
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Olajide OA, Iwuanyanwu VU, Banjo OW, Kato A, Penkova YB, Fleet GWJ, Nash RJ. Iminosugar Amino Acid idoBR1 Reduces Inflammatory Responses in Microglia. Molecules 2022; 27:3342. [PMID: 35630818 PMCID: PMC9143674 DOI: 10.3390/molecules27103342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background. Inflammation is reported to be a key factor in neurodegeneration. The microglia are immune cells present in the central nervous system; their activation results in the release of inflammatory cytokines and is thought to be related to aging and neurodegenerative disorders, such as Alzheimer's disease. (2) Methods. A mouse BV-2 microglia cell line was activated using LPS and the anti-inflammatory cucumber-derived iminosugar amino acid idoBR1, (2R,3R,4R,5S)-3,4,5-trihydroxypiperidine-2-carboxylic acid, was used alongside dexamethasone as the control to determine whether it could reduce the inflammatory responses. (3) Results. A dose-dependent reduction in the LPS-induced production of the proinflammatory factors TNFα, IL-6, and nitric oxide and the transcription factor NF-κB was found. (4) Conclusions. Further investigations of the anti-inflammatory effects of idoBR1 in other models of neurodegenerative diseases are warranted.
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Affiliation(s)
- Olumayokun A. Olajide
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, UK; (O.A.O.); (V.U.I.); (O.W.B.)
| | - Victoria U. Iwuanyanwu
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, UK; (O.A.O.); (V.U.I.); (O.W.B.)
| | - Owolabi W. Banjo
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, UK; (O.A.O.); (V.U.I.); (O.W.B.)
| | - Atsushi Kato
- Department of Hospital Pharmacy, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan;
| | - Yana B. Penkova
- Phytoquest Limited, Plas Gogerddan, Aberystwyth SY23 3EB, UK;
| | - George W. J. Fleet
- Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Oxford OX1 3TA, UK;
| | - Robert J. Nash
- Phytoquest Limited, Plas Gogerddan, Aberystwyth SY23 3EB, UK;
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Hölscher C. Protective properties of GLP-1 and associated peptide hormones in neurodegenerative disorders. Br J Pharmacol 2022; 179:695-714. [PMID: 33900631 PMCID: PMC8820183 DOI: 10.1111/bph.15508] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/11/2022] Open
Abstract
Type 2 diabetes mellitus and the associated desensitisation of insulin signalling has been identified as a risk factor for progressive neurodegenerative disorders such as Alzheimer's disease, Parkinson's disease and others. Glucagon-like peptide 1 (GLP-1) is a hormone that has growth factor-like and neuroprotective properties. Several clinical trials have been conducted, testing GLP-1 receptor agonists in patients with Alzheimer's disease, Parkinson's disease or diabetes-induced memory impairments. The trials showed clear improvements in Alzheimer's disease, Parkinson's disease and diabetic patients. Glucose-dependent insulinotropic polypeptide/gastric inhibitory peptide (GIP) is the 'sister' incretin hormone of GLP-1. GIP analogues have shown neuroprotective effects in animal models of disease and can improve on the effects of GLP-1. Novel dual GLP-1/GIP receptor agonists have been developed that can enter the brain at an enhanced rate. The improved neuroprotective effects of these drugs suggest that they are superior to single GLP-1 receptor agonists and could provide disease-modifying care for Alzheimer's disease and Parkinson's disease patients. LINKED ARTICLES: This article is part of a themed issue on GLP1 receptor ligands (BJP 75th Anniversary). To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v179.4/issuetoc.
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Affiliation(s)
- Christian Hölscher
- The Second Associated Hospital, Neurology DepartmentShanxi Medical UniversityTaiyuanChina
- Academy of Chinese Medical ScienceHenan University of Chinese MedicineZhengzhouChina
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Basic Scientific Evidence Consistent with Etanercept Efficacy Against Alzheimer's Disease. Neuroscience 2021; 484:139. [DOI: 10.1016/j.neuroscience.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Clark IA. How diseases caused by parasites allowed a wider understanding of disease in general: my encounters with parasitology in Australia and elsewhere over the last 50 years. Int J Parasitol 2021; 51:1265-1276. [PMID: 34757090 DOI: 10.1016/j.ijpara.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/18/2021] [Accepted: 10/13/2021] [Indexed: 12/18/2022]
Abstract
This is an account of how it can prove possible to carve a reasonable scientific career by following what brought most scientific thrill rather than pursue a safe, institution-directed, path. The fascination began when I noticed, quite unexpectedly, that the normal mouse immune response causes Babesia microti to die, en masse, inside circulating red cells. It eventuated that prior Bacillus Calmette Guerin infection caused the same outcome, even before the protozoal infection became patent. It also rendered mice quite immune, long term. I acquired an obsession about this telling us how little we know. Surrounded by basic immunologists, parasitologists and virologists in London, I had been given, in the days that funding was ample, the opportunity to follow any promising lead with a free hand. Through Bacillus Calmette Guerin, this meant stumbling through a set of phenomena that were in their infancies, and could be explained only through nebulous novel soluble mediators such as TNF, described the following year as causing the in vivo necrosis of tumours in mice. Beginning with malarial disease pathogenesis, I followed TNF wherever it led, into innate immunity, acute and chronic infections, neurophysiology and neurodegenerative diseases, in all of which states awareness of the role of this cytokine is still growing fast. Many of these steps can be illustrated and expanded upon in parasitic diseases. Covering the importance of TNF in the pathogenesis of neurodegenerative disease has proved to be highly illuminating, scientifically and otherwise. But the insights it has given me into understanding the temptations to which patent-owners can succumb when faced with opportunities to put money before people is not for the faint hearted. Clearly, parasitologists inhabit a much more common-good yet science-orientated, civilised, world.
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Affiliation(s)
- Ian A Clark
- Biomedical Sciences and Biochemistry, Research School of Biology, Australian National University, Canberra, ACT 2601, Australia.
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Singh H, Chawla V, Bala R, Dureja H. Current and Future of Alzheimer's Therapy with the Best Approach. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 19:691-697. [PMID: 32351189 DOI: 10.2174/1871527319666200430000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/30/2020] [Accepted: 03/13/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION In spite of the steady progress in the understanding of the etiopathogenesis of Alzheimer's Disease (AD) for the last 50 years, exceptionally few long-standing drugs are, at present, used for AD therapy. New interventions that either prevent, slow or stop the disease are urgently warranted to overcome the growing AD burden. The aim of this narrative review is to summarize the currently existing preclinical and clinical evidence regarding new drug development and biomarkers for better understanding and focused management of AD. This article reviews the various potential and existing targets /receptors with valid biomarkers applied in recent years to address the early-stage tasks of the AD drug discovery process. A comprehensive literature search was conducted in the relevant databases to identify studies published in recent years. In conclusion, the new approaches seem to aim at examining the prospective neuroprotective activity of disease-modifying drugs in the presymptomatic phases of AD, using biomarkers that detect progression of the disease before the growth of overt dementia.
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Affiliation(s)
- Harminder Singh
- Department of Pharmacology, GGS Medical College, Faridkot, Punjab, India
| | - Viney Chawla
- Department of Pharmaceutics, University Institute of Pharmaceutical Sciences and Research, Baba Farid University of Health Sciences, Faridkot, Punjab, India
| | - Ritu Bala
- Department of Pharmacology, GGS Medical College, Faridkot, Punjab, India
| | - Harish Dureja
- Division of Pharmaceutics, Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
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Yli-Karjanmaa M, Clausen BH, Degn M, Novrup HG, Ellman DG, Toft-Jensen P, Szymkowski DE, Stensballe A, Meyer M, Brambilla R, Lambertsen KL. Topical Administration of a Soluble TNF Inhibitor Reduces Infarct Volume After Focal Cerebral Ischemia in Mice. Front Neurosci 2019; 13:781. [PMID: 31440125 PMCID: PMC6692878 DOI: 10.3389/fnins.2019.00781] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/11/2019] [Indexed: 01/05/2023] Open
Abstract
Background Tumor necrosis factor, which exists both as a soluble (solTNF) and a transmembrane (tmTNF) protein, plays an important role in post-stroke inflammation. The objective of the present study was to test the effect of topical versus intracerebroventricular administration of XPro1595 (a solTNF inhibitor) and etanercept (a solTNF and tmTNF inhibitor) compared to saline on output measures such as infarct volume and post-stroke inflammation in mice. Methods Adult male C57BL/6 mice were treated topically (2.5 mg/ml/1μl/h for 3 consecutive days) or intracerebroventricularly (1.25 mg/kg/0.5 ml, once) with saline, XPro1595, or etanercept immediately after permanent middle cerebral artery occlusion (pMCAO). Mice were allowed to survive 1 or 3 days. Infarct volume, microglial and leukocyte profiles, and inflammatory markers were evaluated. Results We found that topical, and not intracerebroventricular, administration of XPro1595 reduced infarct volume at both 1 and 3 days after pMCAO. Etanercept showed no effect. We observed no changes in microglial or leukocyte populations. XPro1595 increased gene expression of P2ry12 at 1 day and Trem2 at 1 and 3 days, while decreasing Cx3cr1 expression at 1 and 3 days after pMCAO, suggesting a change in microglial activation toward a phagocytic phenotype. Conclusion Our data demonstrate that topical administration of XPro1595 for 3 consecutive days decreases infarct volumes after ischemic stroke, while modifying microglial activation and the inflammatory response post-stroke. This suggests that inhibitors of solTNF hold great promise for future neuroprotective treatment in ischemic stroke.
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Affiliation(s)
- Minna Yli-Karjanmaa
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Bettina Hjelm Clausen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Matilda Degn
- Pediatric Oncology Laboratory, Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Hans Gram Novrup
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Ditte Gry Ellman
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Peter Toft-Jensen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Allan Stensballe
- Department of Health Science and Technology, University of Aalborg, Aalborg, Denmark
| | - Morten Meyer
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Roberta Brambilla
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Kate Lykke Lambertsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Neurology, Odense University Hospital, Odense, Denmark
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Łuc M, Woźniak M, Helemejko M, Rymaszewska J. Tackling Alzheimer's disease: Hypothetical synergism between anti-inflammatory and anti-diabetic agents. Life Sci 2019; 231:116483. [DOI: 10.1016/j.lfs.2019.05.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 02/08/2023]
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Yang W, Jin BH, Chen YJ, Cao C, Zhu JZ, Zhao YZ, Yu XC, Li FZ. The involvement of perivascular spaces or tissues in the facial intradermal brain-targeted delivery. Drug Deliv 2019; 26:393-403. [PMID: 30929532 PMCID: PMC6450571 DOI: 10.1080/10717544.2019.1587044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Our previous work indicates the lymphatic network and perivascular spaces or tissues might be involved in the facial intradermal brain-targeted delivery of Evans blue (EB). In this article, we presented the detailed involvement of both, and the linkage between lymphatic network and perivascular spaces or tissues. The in-vivo imaging, the trigeminal transection and immunohistochemistry were used. In-vivo imaging indicated intradermal injection in the mystacial pad (i.d.) delivered EB into the brain at 2-, 6- and 24 h, while intranasal injection (i.n.) delivered EB into the rostral head and intravenous injection (i.v.) diffused EB weakly into the brain. Trigeminal perineurial and epineurial EB occurred along the perivascular spaces or tissues and along brain vessels. EB diffused into the lymphatic vessels and submandibular lymph nodes. Moreover, perineurial and epineurial EB co-located or overlaid with Lyve1 immuno-reactivity and VEGF antibody, and lymphatic network connected with perivascular spaces or tissues, suggesting lymphatic system-perivascular spaces might involve in the EB delivery with i.d. The trigeminal transection reduced the trigeminal epineurial and perineurial EB and brain EB along vessels. EB diffused in the fasciculus and the perineurium, blood and lymphatic vessels in the mystacial pad, mystacial EB overlaid VEGF or Lyve1 antibody. In summary, the dermal-trigeminal-brain perivascular spaces or tissues and the linkage to the lymphatic network mediated the intradermal brain-targeted delivery.
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Affiliation(s)
- Wei Yang
- a College of Pharmaceutical Science , Zhejiang Chinese Medical University , Hangzhou , China.,b School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Bing-Hui Jin
- b School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Ya-Jing Chen
- b School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Chang Cao
- b School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Jia-Zhen Zhu
- a College of Pharmaceutical Science , Zhejiang Chinese Medical University , Hangzhou , China
| | - Ying-Zheng Zhao
- b School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Xi-Chong Yu
- b School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang Province , China
| | - Fan-Zhu Li
- a College of Pharmaceutical Science , Zhejiang Chinese Medical University , Hangzhou , China
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Yu XC, Yang JJ, Jin BH, Xu HL, Zhang HY, Xiao J, Lu CT, Zhao YZ, Yang W. A strategy for bypassing the blood-brain barrier: Facial intradermal brain-targeted delivery via the trigeminal nerve. J Control Release 2017; 258:22-33. [DOI: 10.1016/j.jconrel.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/25/2017] [Accepted: 05/01/2017] [Indexed: 12/16/2022]
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Affiliation(s)
- Ian A Clark
- a Research School of Biology , Australian National University , Canberra , Australia
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14
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Clark IA, Vissel B. Excess cerebral TNF causing glutamate excitotoxicity rationalizes treatment of neurodegenerative diseases and neurogenic pain by anti-TNF agents. J Neuroinflammation 2016; 13:236. [PMID: 27596607 PMCID: PMC5011997 DOI: 10.1186/s12974-016-0708-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/30/2016] [Indexed: 02/06/2023] Open
Abstract
The basic mechanism of the major neurodegenerative diseases, including neurogenic pain, needs to be agreed upon before rational treatments can be determined, but this knowledge is still in a state of flux. Most have agreed for decades that these disease states, both infectious and non-infectious, share arguments incriminating excitotoxicity induced by excessive extracellular cerebral glutamate. Excess cerebral levels of tumor necrosis factor (TNF) are also documented in the same group of disease states. However, no agreement exists on overarching mechanism for the harmful effects of excess TNF, nor, indeed how extracellular cerebral glutamate reaches toxic levels in these conditions. Here, we link the two, collecting and arguing the evidence that, across the range of neurodegenerative diseases, excessive TNF harms the central nervous system largely through causing extracellular glutamate to accumulate to levels high enough to inhibit synaptic activity or kill neurons and therefore their associated synapses as well. TNF can be predicted from the broader literature to cause this glutamate accumulation not only by increasing glutamate production by enhancing glutaminase, but in addition simultaneously reducing glutamate clearance by inhibiting re-uptake proteins. We also discuss the effects of a TNF receptor biological fusion protein (etanercept) and the indirect anti-TNF agents dithio-thalidomides, nilotinab, and cannabinoids on these neurological conditions. The therapeutic effects of 6-diazo-5-oxo-norleucine, ceptriaxone, and riluzole, agents unrelated to TNF but which either inhibit glutaminase or enhance re-uptake proteins, but do not do both, as would anti-TNF agents, are also discussed in this context. By pointing to excess extracellular glutamate as the target, these arguments greatly strengthen the case, put now for many years, to test appropriately delivered ant-TNF agents to treat neurodegenerative diseases in randomly controlled trials.
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Affiliation(s)
- Ian A Clark
- Biomedical Sciences and Biochemistry, Research School of Biology, Australian National University, Acton, Canberra, Australian Capital Territory, 0200, Australia.
| | - Bryce Vissel
- Neurodegeneration Research Group, Garvan Institute, 384 Victoria Street, Sydney, New South Wales, 2010, Australia
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Abstract
Perispinal injection is a novel emerging method of drug delivery to the central nervous system (CNS). Physiological barriers prevent macromolecules from efficiently penetrating into the CNS after systemic administration. Perispinal injection is designed to use the cerebrospinal venous system (CSVS) to enhance delivery of drugs to the CNS. It delivers a substance into the anatomic area posterior to the ligamentum flavum, an anatomic region drained by the external vertebral venous plexus (EVVP), a division of the CSVS. Blood within the EVVP communicates with the deeper venous plexuses of the CSVS. The anatomical basis for this method originates in the detailed studies of the CSVS published in 1819 by the French anatomist Gilbert Breschet. By the turn of the century, Breschet's findings were nearly forgotten, until rediscovered by American anatomist Oscar Batson in 1940. Batson confirmed the unique, linear, bidirectional and retrograde flow of blood between the spinal and cerebral divisions of the CSVS, made possible by the absence of venous valves. Recently, additional supporting evidence was discovered in the publications of American neurologist Corning. Analysis suggests that Corning's famous first use of cocaine for spinal anesthesia in 1885 was in fact based on Breschet's anatomical findings, and accomplished by perispinal injection. The therapeutic potential of perispinal injection for CNS disorders is highlighted by the rapid neurological improvement in patients with otherwise intractable neuroinflammatory disorders that may ensue following perispinal etanercept administration. Perispinal delivery merits intense investigation as a new method of enhanced delivery of macromolecules to the CNS and related structures.
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Affiliation(s)
- Edward Lewis Tobinick
- Institute of Neurological Recovery, 2300 Glades Road, Suite 305E, Boca Raton, FL, 33431, USA.
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McCaulley ME, Grush KA. Alzheimer's Disease: Exploring the Role of Inflammation and Implications for Treatment. Int J Alzheimers Dis 2015; 2015:515248. [PMID: 26664821 PMCID: PMC4664815 DOI: 10.1155/2015/515248] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/21/2015] [Indexed: 11/17/2022] Open
Abstract
Alzheimer's disease (AD) is a neurodegenerative disorder characterized by both structural abnormalities and inflammation in the brain. While recent research has chiefly focused on the structural changes involved in AD, understanding the pathophysiology and associated inflammation of the AD brain helps to elucidate potential therapeutic and preventative options. By exploring the data supporting an inflammatory etiology of AD, we present a case for the use of existing evidence-based treatments addressing inflammation as promising options for treating and preventing AD. We present data demonstrating tumor necrosis factor alpha association with the inflammation of AD. We also discuss data supporting TNF alpha associated inflammation in traumatic brain injury, stroke, and spinal disc associated radiculopathy. We augment this previously unarticulated concept of a unifying pathophysiology of central nervous system disease, with reports of benefits of TNF alpha inhibition in many hundreds of patients with those diseases, including AD. We also assess the pathophysiologic and clinical trial evidence supporting the role of other inflammation resolving treatments in AD. In aggregate, the data from the several potentially effective therapeutic and preventative options contained within this report presents a clearer picture of next steps needed in research of treatment alternatives.
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Affiliation(s)
- Mark E. McCaulley
- Yampa Valley Medical Associates, 940 Central Park Drive, Steamboat Springs, CO 80487, USA
| | - Kira A. Grush
- Yampa Valley Medical Associates, 940 Central Park Drive, Steamboat Springs, CO 80487, USA
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Roerink ME, Groen RJ, Franssen G, Lemmers-van de Weem B, Boerman OC, van der Meer JW. Central delivery of iodine-125-labeled cetuximab, etanercept and anakinra after perispinal injection in rats: possible implications for treating Alzheimer's disease. ALZHEIMERS RESEARCH & THERAPY 2015; 7:70. [PMID: 26560086 PMCID: PMC4642641 DOI: 10.1186/s13195-015-0149-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/25/2015] [Indexed: 12/16/2022]
Abstract
Introduction Alzheimer’s disease is a debilitating condition, and the search for an effective treatment is ongoing. Inflammation, in reaction to amyloid deposition, is thought to accelerate cognitive decline. With tumor necrosis factor α being an important proinflammatory cytokine, a recent trial investigated the effect of the tumor necrosis factor α inhibitor etanercept after peripheral administration in patients with Alzheimer’s disease. Although there was no significant effect, others have claimed spectacular effects of etanercept after perispinal injection. In the present study, the central delivery of drugs with a large molecular weight was evaluated after injection in the cervical perispinal region in rats. If successful, this strategy might increase therapeutic options for patients with Alzheimer’s disease. Methods Nine male Sprague–Dawley rats were given injections of iodine-125–labeled cetuximab (146 kDa), etanercept (51 kDa), and anakinra (17 kDa). Each radioiodinated drug was injected in the perispinal region in two rats and into the dorsal tail vein in one rat. Directly after injection, the rats were placed in a head-down position for 3 minutes to direct blood flow into the valveless vertebral venous system. A single-positron emission computed tomography scan was acquired starting 5 minutes after injection, subsequently the rats were euthanized and bio-distribution was determined. Results Intracranial delivery of the radiolabeled drugs could not be visualized in all but one of the rats. Injected drugs accumulated locally in the perispinal region. Conclusions In this study, no evidence could be found for the delivery of drugs to the central nervous system after perispinal injection. Additional research is needed before this treatment can be used in patients with Alzheimer’s disease.
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Affiliation(s)
- Megan E Roerink
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Rob Jm Groen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Gerben Franssen
- Department Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Otto C Boerman
- Department Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Jos Wm van der Meer
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
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A Neurologist's Guide to TNF Biology and to the Principles behind the Therapeutic Removal of Excess TNF in Disease. Neural Plast 2015. [PMID: 26221543 PMCID: PMC4510439 DOI: 10.1155/2015/358263] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Tumor necrosis factor (TNF) is an ancient and widespread cytokine required in small amounts for much physiological function. Higher concentrations are central to innate immunity, but if unchecked this cytokine orchestrates much chronic and acute disease, both infectious and noninfectious. While being a major proinflammatory cytokine, it also controls homeostasis and plasticity in physiological circumstances. For the last decade or so these principles have been shown to apply to the central nervous system as well as the rest of the body. Nevertheless, whereas this approach has been a major success in treating noncerebral disease, its investigation and potential widespread adoption in chronic neurological conditions has inexplicably stalled since the first open trial almost a decade ago. While neuroscience is closely involved with this approach, clinical neurology appears to be reticent in engaging with what it offers patients. Unfortunately, the basic biology of TNF and its relevance to disease is largely outside the traditions of neurology. The purpose of this review is to facilitate lowering communication barriers between the traditional anatomically based medical specialties through recognition of shared disease mechanisms and thus advance the prospects of a large group of patients with neurodegenerative conditions for whom at present little can be done.
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Sulfhydryl-mediated redox signaling in inflammation: role in neurodegenerative diseases. Arch Toxicol 2015; 89:1439-67. [DOI: 10.1007/s00204-015-1496-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 02/25/2015] [Indexed: 01/05/2023]
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Viola KL, Klein WL. Amyloid β oligomers in Alzheimer's disease pathogenesis, treatment, and diagnosis. Acta Neuropathol 2015; 129:183-206. [PMID: 25604547 DOI: 10.1007/s00401-015-1386-3] [Citation(s) in RCA: 440] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/11/2015] [Accepted: 01/11/2015] [Indexed: 12/22/2022]
Abstract
Protein aggregation is common to dozens of diseases including prionoses, diabetes, Parkinson's and Alzheimer's. Over the past 15 years, there has been a paradigm shift in understanding the structural basis for these proteinopathies. Precedent for this shift has come from investigation of soluble Aβ oligomers (AβOs), toxins now widely regarded as instigating neuron damage leading to Alzheimer's dementia. Toxic AβOs accumulate in AD brain and constitute long-lived alternatives to the disease-defining Aβ fibrils deposited in amyloid plaques. Key experiments using fibril-free AβO solutions demonstrated that while Aβ is essential for memory loss, the fibrillar Aβ in amyloid deposits is not the agent. The AD-like cellular pathologies induced by AβOs suggest their impact provides a unifying mechanism for AD pathogenesis, explaining why early stage disease is specific for memory and accounting for major facets of AD neuropathology. Alternative ideas for triggering mechanisms are being actively investigated. Some research favors insertion of AβOs into membrane, while other evidence supports ligand-like accumulation at particular synapses. Over a dozen candidate toxin receptors have been proposed. AβO binding triggers a redistribution of critical synaptic proteins and induces hyperactivity in metabotropic and ionotropic glutamate receptors. This leads to Ca(2+) overload and instigates major facets of AD neuropathology, including tau hyperphosphorylation, insulin resistance, oxidative stress, and synapse loss. Because different species of AβOs have been identified, a remaining question is which oligomer is the major pathogenic culprit. The possibility has been raised that more than one species plays a role. Despite some key unknowns, the clinical relevance of AβOs has been established, and new studies are beginning to point to co-morbidities such as diabetes and hypercholesterolemia as etiological factors. Because pathogenic AβOs appear early in the disease, they offer appealing targets for therapeutics and diagnostics. Promising therapeutic strategies include use of CNS insulin signaling enhancers to protect against the presence of toxins and elimination of the toxins through use of highly specific AβO antibodies. An AD-dependent accumulation of AβOs in CSF suggests their potential use as biomarkers and new AβO probes are opening the door to brain imaging. Overall, current evidence indicates that Aβ oligomers provide a substantive molecular basis for the cause, treatment and diagnosis of Alzheimer's disease.
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Gaur S, Agnihotri R. Alzheimer's disease and chronic periodontitis: is there an association? Geriatr Gerontol Int 2014; 15:391-404. [PMID: 25511390 DOI: 10.1111/ggi.12425] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2014] [Indexed: 12/17/2022]
Abstract
Alzheimer's disease, an affliction of old age, is one of the leading causes for dementia worldwide. Various risk factors including family history, genetics and infections have been implicated in its pathogenesis. The cognitive decline in this condition is mainly a result of the formation of amyloid deposits that provoke neuroinflammation, ultimately resulting in cell death. Recently, an association between peripheral inflammation and Alzheimer's disease was hypothesized. It was suggested that chronic systemic inflammation worsened the inflammatory processes in the brain. This was mainly attributed to increased levels of pro-inflammatory mediators, such as interleukin-1, interleukin -6 and tumor necrosis factor-α in the plasma. As chronic periodontitis is a widespread peripheral immunoinflammatory condition, it has been proposed to play a significant role in the aggravation of Alzheimer's disease. With this background, the current review focuses on the relationship between Alzheimer's disease and chronic periodontitis, and its therapeutic implications.
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Affiliation(s)
- Sumit Gaur
- Department of Pedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
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Ignatowski TA, Spengler RN, Tobinick E. Authors' reply to Whitlock: Perispinal etanercept for post-stroke neurological and cognitive dysfunction: scientific rationale and current evidence. CNS Drugs 2014; 28:1207-13. [PMID: 25373629 PMCID: PMC4246125 DOI: 10.1007/s40263-014-0212-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Tracey A. Ignatowski
- Department of Pathology and Anatomical Sciences and Program for Neuroscience, School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, NY USA
| | | | - Edward Tobinick
- Institute of Neurological Recovery, 2300 Glades Road Suite 305E, Boca Raton, FL 33431 USA
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Abstract
The incretin hormone glucagon-like peptide 1 (GLP-1) has many effects in the body. It is best known for the 'incretin effect', facilitating insulin release from the pancreas under hyperglycaemic conditions. Building on this, GLP-1 mimetics have been developed as a treatment for type 2 diabetes. In the course of monitoring of patients, it has become apparent that GLP-1 mimetics have a range of other physiological effects in the body. In preclinical trials, a substantial body of evidence has been built that these mimetics have neuroprotective and anti-inflammatory effects. GLP-1 also has very similar growth-factor-like properties to insulin, which is presumably the underlying basis of the neuroprotective effects. In preclinical studies of Alzheimer's disease (AD), Parkinson's disease (PD), stroke and other neurodegenerative disorders, it has been shown that most GLP-1 mimetics cross the blood-brain barrier and show impressive neuroprotective effects in numerous studies. In animal models of AD, GLP-1 mimetics such as exendin-4, liraglutide and lixisenatide have shown protective effects in the CNS by reducing β-amyloid plaques, preventing loss of synapses and memory impairments, and reducing oxidative stress and the chronic inflammatory response in the brain. In animal models of PD, exendin-4 showed protection of dopaminergic neurons in the substantia nigra and prevention of dopamine loss in the basal ganglia while preserving motor control. These encouraging findings have spawned several clinical trials, some of which have shown encouraging initial results. Therefore, GLP-1 mimetics show great promise as a novel treatment for neurodegenerative conditions.
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Affiliation(s)
- Christian Hölscher
- Division of Biomedical and Life Sciences, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YQ, UK
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Gisondi P, Sala F, Alessandrini F, Avesani V, Zoccatelli G, Beltramello A, Moretto G, Gambina G, Girolomoni G. Mild Cognitive Impairment in Patients with Moderate to Severe Chronic Plaque Psoriasis. Dermatology 2014; 228:78-85. [DOI: 10.1159/000357220] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 11/09/2013] [Indexed: 11/19/2022] Open
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Tobinick E. Perispinal etanercept: a new therapeutic paradigm in neurology. Expert Rev Neurother 2014; 10:985-1002. [DOI: 10.1586/ern.10.52] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
There is increasing recognition of the involvement of the immune signaling molecule, tumor necrosis factor (TNF), in the pathophysiology of stroke and chronic brain dysfunction. TNF plays an important role both in modulating synaptic function and in the pathogenesis of neuropathic pain. Etanercept is a recombinant therapeutic that neutralizes pathologic levels of TNF. Brain imaging has demonstrated chronic intracerebral microglial activation and neuroinflammation following stroke and other forms of acute brain injury. Activated microglia release TNF, which mediates neurotoxicity in the stroke penumbra. Recent observational studies have reported rapid and sustained improvement in chronic post-stroke neurological and cognitive dysfunction following perispinal administration of etanercept. The biological plausibility of these results is supported by independent evidence demonstrating reduction in cognitive dysfunction, neuropathic pain, and microglial activation following the use of etanercept, as well as multiple studies reporting improvement in stroke outcome and cognitive impairment following therapeutic strategies designed to inhibit TNF. The causal association between etanercept treatment and reduction in post-stroke disability satisfy all of the Bradford Hill Criteria: strength of the association; consistency; specificity; temporality; biological gradient; biological plausibility; coherence; experimental evidence; and analogy. Recognition that chronic microglial activation and pathologic TNF concentration are targets that may be therapeutically addressed for years following stroke and other forms of acute brain injury provides an exciting new direction for research and treatment.
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Yiannopoulou KG, Papageorgiou SG. Current and future treatments for Alzheimer's disease. Ther Adv Neurol Disord 2013; 6:19-33. [PMID: 23277790 PMCID: PMC3526946 DOI: 10.1177/1756285612461679] [Citation(s) in RCA: 381] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Alzheimer's dementia (AD) is increasingly being recognized as one of the most important medical and social problems in older people in industrialized and non-industrialized nations. To date, only symptomatic treatments exist for this disease, all trying to counterbalance the neurotransmitter disturbance. Three cholinesterase inhibitors (CIs) are currently available and have been approved for the treatment of mild to moderate AD. A further therapeutic option available for moderate to severe AD is memantine, an N-methyl-D-aspartate receptor noncompetitive antagonist. Treatments capable of stopping or at least effectively modifying the course of AD, referred to as 'disease-modifying' drugs, are still under extensive research. To block the progression of the disease they have to interfere with the pathogenic steps responsible for the clinical symptoms, including the deposition of extracellular amyloid β plaques and intracellular neurofibrillary tangle formation, inflammation, oxidative damage, iron deregulation and cholesterol metabolism. In this review we discuss current symptomatic treatments and new potential disease-modifying therapies for AD that are currently being studied in phase I-III trials.
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Tobinick E, Kim NM, Reyzin G, Rodriguez-Romanacce H, DePuy V. Selective TNF inhibition for chronic stroke and traumatic brain injury: an observational study involving 629 consecutive patients treated with perispinal etanercept. CNS Drugs 2012; 26:1051-70. [PMID: 23100196 DOI: 10.1007/s40263-012-0013-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Brain injury from stroke and traumatic brain injury (TBI) may result in a persistent neuroinflammatory response in the injury penumbra. This response may include microglial activation and excess levels of tumour necrosis factor (TNF). Previous experimental data suggest that etanercept, a selective TNF inhibitor, has the ability to ameliorate microglial activation and modulate the adverse synaptic effects of excess TNF. Perispinal administration may enhance etanercept delivery across the blood-CSF barrier. OBJECTIVE The objective of this study was to systematically examine the clinical response following perispinal administration of etanercept in a cohort of patients with chronic neurological dysfunction after stroke and TBI. METHODS After approval by an independent external institutional review board (IRB), a chart review of all patients with chronic neurological dysfunction following stroke or TBI who were treated open-label with perispinal etanercept (PSE) from November 1, 2010 to July 14, 2012 at a group medical practice was performed. RESULTS The treated cohort included 629 consecutive patients. Charts of 617 patients following stroke and 12 patients following TBI were reviewed. The mean age of the stroke patients was 65.8 years ± 13.15 (range 13-97). The mean interval between treatment with PSE and stroke was 42.0 ± 57.84 months (range 0.5-419); for TBI the mean interval was 115.2 ± 160.22 months (range 4-537). Statistically significant improvements in motor impairment, spasticity, sensory impairment, cognition, psychological/behavioural function, aphasia and pain were noted in the stroke group, with a wide variety of additional clinical improvements noted in individuals, such as reductions in pseudobulbar affect and urinary incontinence. Improvements in multiple domains were typical. Significant improvement was noted irrespective of the length of time before treatment was initiated; there was evidence of a strong treatment effect even in the subgroup of patients treated more than 10 years after stroke and TBI. In the TBI cohort, motor impairment and spasticity were statistically significantly reduced. DISCUSSION Irrespective of the methodological limitations, the present results provide clinical evidence that stroke and TBI may lead to a persistent and ongoing neuroinflammatory response in the brain that is amenable to therapeutic intervention by selective inhibition of TNF, even years after the acute injury. CONCLUSION Excess TNF contributes to chronic neurological, neuropsychiatric and clinical impairment after stroke and TBI. Perispinal administration of etanercept produces clinical improvement in patients with chronic neurological dysfunction following stroke and TBI. The therapeutic window extends beyond a decade after stroke and TBI. Randomized clinical trials will be necessary to further quantify and characterize the clinical response.
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Affiliation(s)
- Edward Tobinick
- Institute of Neurological Recovery, 100 UCLA Medical Plaza, Suites 205-210, Los Angeles, CA 90095, USA.
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Anti-inflammatory effects of maslinic acid, a natural triterpene, in cultured cortical astrocytes via suppression of nuclear factor-kappa B. Eur J Pharmacol 2011; 672:169-74. [DOI: 10.1016/j.ejphar.2011.09.175] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 09/17/2011] [Accepted: 09/19/2011] [Indexed: 01/10/2023]
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Cavanagh C, Colby-Milley J, Farso M, Krantic S, Quirion R. Early molecular and synaptic dysfunctions in the prodromal stages of Alzheimer’s disease: focus on TNF-α and IL-1β. FUTURE NEUROLOGY 2011. [DOI: 10.2217/fnl.11.50] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Alterations in cytokine expression as well as deficits in synaptic activity are two features observed in early, prodromal stages of Alzheimer’s disease (AD). The cytokines TNF-α and IL-1β are not only mediators of immune responses, but are also involved in regulating synaptic activity through their effects on neuronal excitability and Hebbian plasticity. We propose that early changes occurring in the AD brain, such as increases in soluble amyloid-β oligomers, may increase the expression of certain cytokines and subsequently cause alterations in cytokine-mediated synaptic activity. A shift of focus towards the prodromal stages of AD, which incorporate the earliest detectable molecular, electrophysiological and behavioral alterations, may provide novel therapeutic targets and potential biomarkers for this currently incurable neurodegenerative disease.
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Affiliation(s)
- Chelsea Cavanagh
- Douglas Mental Health University Institute, Dept of Psychiatry, McGill University, 6875 Boul. Lasalle, Montreal, Quebec H4H 1R3, Canada
- McGill University, 845 Sherbrooke St. West. Montreal, Quebec H3A 2T5, Canada
| | - Jessica Colby-Milley
- Douglas Mental Health University Institute, Dept of Psychiatry, McGill University, 6875 Boul. Lasalle, Montreal, Quebec H4H 1R3, Canada
- McGill University, 845 Sherbrooke St. West. Montreal, Quebec H3A 2T5, Canada
| | - Mark Farso
- Douglas Mental Health University Institute, Dept of Psychiatry, McGill University, 6875 Boul. Lasalle, Montreal, Quebec H4H 1R3, Canada
- McGill University, 845 Sherbrooke St. West. Montreal, Quebec H3A 2T5, Canada
| | - Slavica Krantic
- Douglas Mental Health University Institute, Dept of Psychiatry, McGill University, 6875 Boul. Lasalle, Montreal, Quebec H4H 1R3, Canada
- McGill University, 845 Sherbrooke St. West. Montreal, Quebec H3A 2T5, Canada
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Abstract
BACKGROUND Thrombolytic therapy reduces stroke size and disability by reperfusion and salvage of ischaemic penumbra. Emerging evidence suggests that retrieved penumbra may be the site of ongoing inflammatory pathology that includes extensive microglial activation. Microglial activation may be associated with excessive levels of tumour necrosis factor (TNF) and resultant neurotoxicity. Etanercept, a potent biologic TNF antagonist, reduces microglial activation in experimental models and has been therapeutically effective in models of brain and neuronal injury. Perispinal administration of etanercept, previously reported to be beneficial for the treatment of Alzheimer's disease, may facilitate delivery of etanercept into the brain. OBJECTIVE The objective of this report is to document the initial clinical response to perispinal etanercept in the first chronic stroke cohort so treated. METHODS Three consecutive patients with stable and persistent chronic neurological deficits due to strokes that had failed to resolve despite previous treatment and rehabilitation were evaluated at an outpatient clinic. They were treated off-label with perispinal etanercept as part of the clinic's practice of medicine. RESULTS All three patients had chronic hemiparesis, in addition to other stroke deficits. Their stroke distributions were right middle cerebral artery (MCA), brainstem (medulla) and left MCA. The two patients with MCA strokes had both received acute thrombolytic therapy. Each of the three patients was treated with an initial dose of perispinal etanercept 13, 35 and 36 months following their acute stroke, respectively. Significant clinical improvement following perispinal etanercept administration was observed in all patients. Onset of clinical response was evident within 10 minutes of perispinal injection in all patients. Improvements in hemiparesis, gait, hand function, hemi-sensory deficits, spatial perception, speech, cognition and behaviour were noted among the patients treated. Each patient received a second perispinal etanercept dose at 22-26 days after the first dose that was followed by additional clinical improvement. CONCLUSIONS Open-label administration of perispinal etanercept resulted in rapid neurological improvement in three consecutive patients with chronic neurological dysfunction due to strokes occurring 13-36 months earlier. These results suggest that stroke may result in chronic TNF-mediated pathophysiology that may be amenable to therapeutic intervention long after the acute event. Randomized clinical trials of perispinal etanercept for selected patients with chronic neurological dysfunction following stroke are indicated.
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Affiliation(s)
- Edward Tobinick
- Institute for Neurological Research, a private medical group, inc., Los Angeles, California, USA.
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The sad plight of multiple sclerosis research (low on fact, high on fiction): critical data to support it being a neurocristopathy. Inflammopharmacology 2010; 18:265-90. [PMID: 20862553 DOI: 10.1007/s10787-010-0054-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 08/26/2010] [Indexed: 10/19/2022]
Abstract
The literature for evidence of autoimmunity in multiple sclerosis (MS) is analysed critically. In contrast to the accepted theory, the human counterpart of the animal model experimental autoimmune demyelinating disease, experimental allergic encephalomyelitis (EAE), is not MS but a different demyelinating disorder, i.e. acute disseminated encephalomyelitis and acute haemorrhagic leucoencephalitis. Extrapolation of EAE research to MS has been guided largely by faith and a blind acceptance rather than sound, scientific rationale. No specific or sensitive immunological test exists that is diagnostic of MS despite the extensive application of modern technology. Immunosuppression has failed to have any consistent effect on prognosis or disease progression. The available data on MS immunotherapy are conflicting, at times contradictory and are based on findings in animals with EAE. They show predominantly a 30% effect in relapsing/remitting MS which suggests powerful placebo effect. Critical analysis of the epidemiological data shows no association with any specific autoimmune diseases, but does suggest that geographic factors and age at development posit an early onset possibly dependent on environmental influences. Certain neurological diseases are, however, found in association with MS, namely hypertrophic peripheral neuropathy, neurofibromatosis-1, cerebral glioma, glioblastoma multiforme and certain familial forms of narcolepsy. These share a common genetic influence possibly from genes on chromosome 17 affecting cell proliferation. A significant number of these disorders are of neural crest origin, the classical example being abnormalities of the Schwann cell. These and other data allow us to propose that MS is a developmental neural crest disorder, i.e. a cristopathy, implicating glial cell dysfunction with diffuse blood-brain barrier breakdown. The data on transcription factor SOX10 mutations in animals may explain these bizarre clinical associations with MS and the phenotypic variability of such alterations (Cossais et al. 2010). Research directed to the area of neural crest associations is likely to be rewarding.
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Aderinwale OG, Ernst HW, Mousa SA. Current therapies and new strategies for the management of Alzheimer's disease. Am J Alzheimers Dis Other Demen 2010; 25:414-24. [PMID: 20601643 PMCID: PMC10845420 DOI: 10.1177/1533317510372372] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Alzheimer's disease (AD) is a devastating neurodegenerative disorder that currently affects millions of Americans. There is no cure at present and no real long-term hope for patients with AD. While partially effective in improving symptoms, currently available treatments approved by the US Food and Drug Administration (FDA) do not halt progression of AD, or address the underlying mechanism of the disease, in part because the etiology of AD is still an active area of investigation. Identification of risk factors and the pathogenic mechanism of AD hold the promise of bringing forth novel treatments and perhaps even a cure. In this review, we will summarize some of the risk factors for AD, AD diagnosis, and current treatments. Novel therapeutic strategies such as inhibition of beta-amyloid peptide (Abeta), tau-mediated pathogenesis, and receptors for advanced glycation end products (RAGE), as well as neuroprotective and anti-inflammatory approaches and the impact of cholesterol-lowering, botanical, and nutritional agents are also reviewed.
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Affiliation(s)
- Olapeju G Aderinwale
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY 12144, USA
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Adén U, Favrais G, Plaisant F, Winerdal M, Felderhoff-Mueser U, Lampa J, Lelièvre V, Gressens P. Systemic inflammation sensitizes the neonatal brain to excitotoxicity through a pro-/anti-inflammatory imbalance: key role of TNFalpha pathway and protection by etanercept. Brain Behav Immun 2010; 24:747-58. [PMID: 19861157 DOI: 10.1016/j.bbi.2009.10.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Revised: 10/21/2009] [Accepted: 10/22/2009] [Indexed: 10/20/2022] Open
Abstract
Systemic inflammation sensitizes the perinatal brain to an ischemic/excitotoxic insult but the mechanisms are poorly understood. We hypothesized that the mechanisms involve an imbalance between pro- and anti-inflammatory factors. A well characterized mouse model where a systemic injection of IL-1beta during the first five postnatal days (inflammatory insult) is combined with an intracerebral injection of the glutamatergic analogue ibotenate (excitotoxic insult) at postnatal day 5 was used. Following the inflammatory insult alone, there was a transient induction of IL-1beta and TNFalpha, compared with controls measured by quantitative PCR, ELISA, and Western blot. Following the combined inflammatory and excitotoxic insult, there was an induction of IL-1beta, TNFalpha, and IL-6 but not of IL-10 and TNFR1, indicating an altered pro-/anti-inflammatory balance after IL-1beta sensitized lesion. We then tested the hypothesis that the TNFalpha pathway plays a key role in the sensitization and insult using TNFalpha blockade (etanercept) and TNFalpha(-/-) mice. Etanercept given before the insult did not affect brain damage, but genetic deletion of TNFalpha or TNFalpha blockade by etanercept given after the combined inflammatory and excitotoxic insult reduced brain damage by 50%. We suggest this protective effect was centrally mediated, since systemic TNFalpha administration in the presence of an intact blood-brain barrier did not aggravate the damage and etanercept almost abolished cerebral TNFalpha production. In summary, sensitization was, at least partly, mediated by an imbalance between pro- and anti-inflammatory cytokines. Cerebral TNFalpha played a key role in mediating brain damage after the combined inflammatory and excitatory insult.
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Cañas N, Gorina R, Planas A, Vergés J, Montell E, García A, López M. Chondroitin sulfate inhibits lipopolysaccharide-induced inflammation in rat astrocytes by preventing nuclear factor kappa B activation. Neuroscience 2010; 167:872-9. [DOI: 10.1016/j.neuroscience.2010.02.069] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 02/22/2010] [Accepted: 02/23/2010] [Indexed: 01/22/2023]
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Concord grape juice supplementation improves memory function in older adults with mild cognitive impairment. Br J Nutr 2009; 103:730-4. [DOI: 10.1017/s0007114509992364] [Citation(s) in RCA: 248] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Concord grape juice contains polyphenol compounds, which have antioxidant and anti-inflammatory properties and influence neuronal signalling. Concord grape juice supplementation has been shown to reduce inflammation, blood pressure and vascular pathology in individuals with CVD, and consumption of such flavonoid-containing foods is associated with a reduced risk for dementia. In addition, preliminary animal data have indicated improvement in memory and motor function with grape juice supplementation, suggesting potential for cognitive benefit in ageing humans. In this initial investigation of neurocognitive effects, we enrolled twelve older adults with memory decline but not dementia in a randomised, placebo-controlled, double-blind trial with Concord grape juice supplementation for 12 weeks. We observed significant improvement in a measure of verbal learning and non-significant enhancement of verbal and spatial recall. There was no appreciable effect of the intervention on depressive symptoms and no effect on weight or waist circumference. A small increase in fasting insulin was observed for those consuming grape juice. These preliminary findings suggest that supplementation with Concord grape juice may enhance cognitive function for older adults with early memory decline and establish a basis for more comprehensive investigations to evaluate potential benefit and assess mechanisms of action.
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Holmes C, Cotterell D. Role of infection in the pathogenesis of Alzheimer's disease: implications for treatment. CNS Drugs 2009; 23:993-1002. [PMID: 19958038 DOI: 10.2165/11310910-000000000-00000] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
While our understanding of the neuropathology of Alzheimer's disease continues to grow, its pathogenesis remains a subject of intense debate. Genetic mutations contribute to a minority of early-onset autosomal dominant cases, but most cases are of either late-onset familial or sporadic form. CNS infections, most notably herpes simplex virus type 1, Chlamydophila pneumoniae and several types of spirochetes, have been previously suggested as possible aetiological agents in the development of sporadic Alzheimer's disease but with little consistent evidence. However, peripheral infections may have a role to play in accelerating neurodegeneration in Alzheimer's disease by activating already primed microglial cells within the CNS. Potential pharmacological interventions could aim at modification of this peripheral inflammatory response through targeting various agents involved in this inflammatory pathway. However, benefit could also be gained clinically through the meticulous detection, treatment and prevention of infections in individuals either alone or in combination with anti-inflammatory therapy.
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Affiliation(s)
- Clive Holmes
- University of Southampton, Memory Assessment and Research Centre, Moorgreen Hospital, Southampton, UK.
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DellaGioia N, Hannestad J. A critical review of human endotoxin administration as an experimental paradigm of depression. Neurosci Biobehav Rev 2009; 34:130-43. [PMID: 19666048 DOI: 10.1016/j.neubiorev.2009.07.014] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 07/22/2009] [Accepted: 07/24/2009] [Indexed: 12/12/2022]
Abstract
The syndrome called depression may represent the common final pathway at which different aetiopathogenic processes converge. One such aetiopathogenic process is innate immune system activation. Some depressed patients have increased levels of inflammatory cytokines and other immunologic abnormalities. It is not known whether immune system activation contributes to the pathogenesis of depressive symptoms. Supporting this possibility is the observation that in both rodents and humans, exogenous immune stimuli such as endotoxin can produce symptoms that resemble depression. A new approach to depression research would be to use immune stimuli to elicit depressive symptoms in humans. Here we review each of the symptoms elicited in humans by endotoxin administration, and compare this model to two other immune depression paradigms: interferon-alpha treatment and typhoid vaccine administration, to assess to what degree endotoxin administration represents a valid model of immune depression. We also review corresponding behavioral changes in rodents and the potential molecular pathways through which immune system activation produces each symptom.
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Affiliation(s)
- Nicole DellaGioia
- Yale Department of Psychiatry, Clinical Neuroscience Research Unit, Yale University School of Medicine, New Haven, CT 06519, USA
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Tobinick E. Perispinal etanercept for neuroinflammatory disorders. Drug Discov Today 2009; 14:168-77. [DOI: 10.1016/j.drudis.2008.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 10/13/2008] [Accepted: 10/22/2008] [Indexed: 12/31/2022]
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Andrade C, Radhakrishnan R. The prevention and treatment of cognitive decline and dementia: An overview of recent research on experimental treatments. Indian J Psychiatry 2009; 51:12-25. [PMID: 19742190 PMCID: PMC2738400 DOI: 10.4103/0019-5545.44900] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The prevention and treatment of cognitive impairment in the elderly has assumed increasing importance in an aging population. This article presents a qualitative review of recent research on experimental interventions for the prevention and treatment of mild cognitive impairment and Alzheimer's disease in elderly subjects. Interventions addressed range from lifestyle measures to pharmacological treatments. Epidemiological studies suggest that dietary measures, physical exercise, and mental activity may reduce the risk of cognitive impairment and Alzheimer's disease in elderly subjects. Statins may protect against incident dementia, and lithium may convey similar benefits to bipolar patients. Ginkgo appears ineffective as a primary preventive measure. Donepezil but not Vitamin E may benefit persons with mild cognitive impairment. Experimental treatments potentially useful for Alzheimer's disease include dimebon, PBT2 and etanercept; the safety and efficacy of the Alzheimer's vaccine remains to be proven, and growth hormone secretagogue and tarenflurbil are likely ineffective. Herbal treatments merit study in elderly subjects with cognitive syndromes.
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Affiliation(s)
- Chittaranjan Andrade
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore - 560 029, India
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Tobinick EL, Gross H. Rapid improvement in verbal fluency and aphasia following perispinal etanercept in Alzheimer's disease. BMC Neurol 2008; 8:27. [PMID: 18644112 PMCID: PMC2500042 DOI: 10.1186/1471-2377-8-27] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Accepted: 07/21/2008] [Indexed: 12/31/2022] Open
Abstract
Background Recent clinical studies point to rapid and sustained clinical, cognitive, and behavioral improvement in both Alzheimer's disease and primary progressive aphasia following weekly perispinal administration of etanercept, a TNF-alpha inhibitor that acts by blocking the binding of this cytokine to its receptors. This outcome is concordant with recent basic science studies suggesting that TNF-alpha functions in vivo as a gliotransmitter that regulates synaptic function in the brain. We hypothesized that perispinal etanercept had the potential to improve verbal function in Alzheimer's disease, so we included several standarized measures of verbal ability to evaluate language skills in a clinical trial of perispinal etanercept for Alzheimer's disease. Methods This was a prospective, single-center, open-label, pilot study, in which 12 patients with mild-to-severe Alzheimer's disease were administered etanercept, 25–50 mg, weekly by perispinal administration for six months. Two additional case studies are presented. Results Two-tailed, paired t-tests were conducted comparing baseline performance to 6-month performance on all neuropsychological measures. Test batteries included the California Verbal Learning Test-Second Edition, Adult Version; Logical Memory I and II(WMS-LM-II) from the Wechsler Memory Scale-Abbreviated; the Comprehensive Trail Making Test (TMT); Boston Naming Test; and letter(FAS) and category verbal fluency. All measures revealed a significant effect except for the Boston Naming Test and the TMT-4, with WMS-LM-II being marginally significant at p = .05. The FAS test for letter fluency was most highly significant with a p < 0.0007. In addition, rapid improvement in verbal fluency and aphasia in two patients with dementia, beginning minutes after perispinal etanercept administration, is documented. Conclusion In combination with the previously reported results of perispinal etanercept in Alzheimer's disease and primary progressive aphasia, these results further argue that larger scale studies of this therapeutic intervention, including Phase 3 trials, are warranted in dementias. In addition, these results may provide insight into the basic pathophysiologic mechanisms underlying Alzheimer's disease and related forms of dementia, and suggest the existence of novel, rapidly reversible, TNF-mediated pathophysiologic mechanisms in Alzheimer's disease which are worthy of further investigation.
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Affiliation(s)
- Edward L Tobinick
- Institute for Neurological Research, a private medical group, inc., Los Angeles, USA.
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Tobinick E. Perispinal etanercept produces rapid improvement in primary progressive aphasia: identification of a novel, rapidly reversible TNF-mediated pathophysiologic mechanism. MEDSCAPE JOURNAL OF MEDICINE 2008; 10:135. [PMID: 18679537 PMCID: PMC2491668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Primary progressive aphasia (PPA) is an uncommon form of progressive dementia for which there exists no established treatment. The underlying pathology may be that of either frontotemporal dementia or Alzheimer's disease. Increasing evidence suggests that excess tumor necrosis factor (TNF) may play a central role in Alzheimer's disease. Additionally, excess TNF has been documented in patients with frontotemporal dementia. Excess TNF may therefore represent a therapeutic target in PPA. Etanercept, an anti-TNF fusion protein, binds to TNF, thereby reducing its biologic effect. Emerging evidence suggests that perispinal administration of etanercept may have therapeutic efficacy for Alzheimer's disease. This evidence, in combination, supports a rationale for the use of perispinal etanercept for the treatment of PPA. This report documents rapid improvement in verbal abilities, beginning within 20 minutes of perispinal etanercept, in a patient with severe PPA. With repeated weekly dosing, sustained improvement at 1 month is documented, with a more than 10-point improvement in the patient's abilities to perform activities of daily living as measured by a standardized instrument, the Alzheimer's Disease Cooperative Study-Activities of Daily Living inventory. Rapid clinical improvement in PPA following perispinal etanercept administration may be related to TNF's role as a gliotransmitter and modulator of synaptic communication in the brain. These results may provide insight into the basic pathophysiologic mechanisms underlying PPA and related forms of dementia and suggest the existence of novel, rapidly reversible, TNF-mediated pathophysiologic mechanisms in both PPA and Alzheimer's disease. Further study of this therapeutic method is indicated.
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Affiliation(s)
- Edward Tobinick
- University of California Los Angeles; Institute for Neurological Research, Los Angeles, California, USA.
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