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Syeed R, Mujib A, Bansal Y, Mohsin M, Nafees A, Malik MQ, Mamgain J, Ejaz B, Dewir YH, Magyar-Tábori K. Tissue-Specific Natural Synthesis of Galanthaminein Zephyranthes Species and Its Accumulation in Different In Vitro-Grown Organs Following Methyl Jasmonate Treatment. PLANTS (BASEL, SWITZERLAND) 2024; 13:1931. [PMID: 39065458 PMCID: PMC11280839 DOI: 10.3390/plants13141931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/08/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024]
Abstract
Galanthamine is an immensely valuable alkaloid exhibiting anti-cancer and antiviral activity. The cultivation of plant tissues in in vitro conditions is a good source for the synthesis and enrichment of secondary metabolites of commercial interest. In this study, the Amaryllidaceae alkaloid galanthamine was quantified in three Zephyranthes species, such as Zephyranthes candida, Zephyranthes grandiflora, and Zephyranthes citrina, and the impact of the methyl jasmonate (MJ) signaling molecule on galanthamine accumulation was monitored in in vitro-derived plant tissues. This is the first ever study of the MJ-regulated accumulation of galanthamine in in vitro-grown Zephyranthes tissues. Shoot regeneration was obtained in all three Zephyranthes species on Murashige and Skoog (MS) medium containing 2.0 mgL-1 benzylaminopurine (BAP) + 0.5 mgL-1 naphthalene acetic acid (NAA). The regenerated shoots were rooted on a medium containing 2.0 mgL-1 indole butyric acid (IBA). A GC-MS study of Zephyranthes extracts revealed the presence of 34 phyto-compounds of varied levels with therapeutic activities against diseases. The galanthamine content was quantified in plant parts of the three Zephyranthes species using high-performance thin layer chromatography (HPTLC); the maximum was found in Z. candida bulb (2.41 µg g-1 dry wt.), followed by Z. grandiflora (2.13 µg g-1 dry wt.), and then Z. citrina (2.02 µg g-1 dry wt.). The galanthamine content showed bulb > leaf > root source order. The in vitro-generated plantlets were treated with different MJ concentrations, and the galanthamine yield was measured in bulb, leaf, and root tissues. The highest galanthamine content was recorded in bulbs of Z. candida (3.97 µg g-1 dry wt.) treated with 150 µM MJ, showing an increase of 64.73% compared to the control. This accumulation may be attributed to MJ-induced stress, highlighting the potential commercial synthesis of galanthamine in vitro.
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Affiliation(s)
- Rukaya Syeed
- Cellular Differentiation and Molecular Genetics Section, Department of Botany, Jamia Hamdard, New Delhi 110062, India; (R.S.); (Y.B.); (M.M.); (A.N.); (M.Q.M.); (J.M.); (B.E.)
| | - A. Mujib
- Cellular Differentiation and Molecular Genetics Section, Department of Botany, Jamia Hamdard, New Delhi 110062, India; (R.S.); (Y.B.); (M.M.); (A.N.); (M.Q.M.); (J.M.); (B.E.)
| | - Yashika Bansal
- Cellular Differentiation and Molecular Genetics Section, Department of Botany, Jamia Hamdard, New Delhi 110062, India; (R.S.); (Y.B.); (M.M.); (A.N.); (M.Q.M.); (J.M.); (B.E.)
| | - Mohammad Mohsin
- Cellular Differentiation and Molecular Genetics Section, Department of Botany, Jamia Hamdard, New Delhi 110062, India; (R.S.); (Y.B.); (M.M.); (A.N.); (M.Q.M.); (J.M.); (B.E.)
| | - Afeefa Nafees
- Cellular Differentiation and Molecular Genetics Section, Department of Botany, Jamia Hamdard, New Delhi 110062, India; (R.S.); (Y.B.); (M.M.); (A.N.); (M.Q.M.); (J.M.); (B.E.)
| | - Moien Qadir Malik
- Cellular Differentiation and Molecular Genetics Section, Department of Botany, Jamia Hamdard, New Delhi 110062, India; (R.S.); (Y.B.); (M.M.); (A.N.); (M.Q.M.); (J.M.); (B.E.)
| | - Jyoti Mamgain
- Cellular Differentiation and Molecular Genetics Section, Department of Botany, Jamia Hamdard, New Delhi 110062, India; (R.S.); (Y.B.); (M.M.); (A.N.); (M.Q.M.); (J.M.); (B.E.)
| | - Bushra Ejaz
- Cellular Differentiation and Molecular Genetics Section, Department of Botany, Jamia Hamdard, New Delhi 110062, India; (R.S.); (Y.B.); (M.M.); (A.N.); (M.Q.M.); (J.M.); (B.E.)
| | - Yaser Hassan Dewir
- Plant Production Department, College of Food and Agriculture Sciences, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Katalin Magyar-Tábori
- Research Institute of Nyíregyháza, Institutes for Agricultural Research and Educational Farm (IAREF), University of Debrecen, P.O. Box 12, 4400 Nyíregyháza, Hungary;
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Kim J, Jahng S, Kim S, Kang Y. A Comparison of Item Characteristics and Test Information Between the K-MMSE~2:SV and K-MMSE. Dement Neurocogn Disord 2024; 23:117-126. [PMID: 39113752 PMCID: PMC11300688 DOI: 10.12779/dnd.2024.23.3.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 08/10/2024] Open
Abstract
Background and Purpose The Korean-Mini Mental State Examination, 2nd edition (K-MMSE~2) was recently released. This study aimed to determine whether the K-MMSE~2: Standard Version (K-MMSE~2:SV) had the same test characteristics as the K-MMSE. Methods A total of 1,514 healthy community-based participants aged 19 to 90 years were administered the K-MMSE~2:SV Blue Form along with the language items from the K-MMSE. The item and test characteristics and test information for the K-MMSE~2:SV and K-MMSE were compared using Item Response Theory analysis. Results Item discriminations for the K-MMSE~2:SV and K-MMSE were above the moderate range for all items except Recall. Most of the items on the K-MMSE~2:SV and K-MMSE had item category difficulty in the very easy or easy range. The test information curve (TIC) showed that the K-MMSE~2:SV and K-MMSE provide almost the same amount of information (27.86 vs. 28.44), with both tests providing the most information at an ability level of -1.57. The generalizability (G) coefficient for the K-MMSE~2:SV and K-MMSE was 0.99. Conclusions These results indicate that the K-MMSE~2:SV and K-MMSE are equally optimal tests for screening for mild cognitive impairment and early dementia. Given that the amount of test information provided by the two tests was almost identical, the shapes of the TICs were very similar, and the G coefficient was close to 1, we can conclude that the K-MMSE and K-MMSE~2:SV are equivalent tests.
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Affiliation(s)
- Jihyang Kim
- Department of Psychology, College of Social Sciences, Hallym University, Chuncheon, Korea
| | - Seungmin Jahng
- Department of Psychology, College of Social Sciences, Sungkyunkwan University, Seoul, Korea
| | - SangYun Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yeonwook Kang
- Department of Psychology, College of Social Sciences, Hallym University, Chuncheon, Korea
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Sequeira L, Benfeito S, Fernandes C, Lima I, Peixoto J, Alves C, Machado CS, Gaspar A, Borges F, Chavarria D. Drug Development for Alzheimer's and Parkinson's Disease: Where Do We Go Now? Pharmaceutics 2024; 16:708. [PMID: 38931832 PMCID: PMC11206728 DOI: 10.3390/pharmaceutics16060708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
Neurodegenerative diseases (NDs) are a set of progressive, chronic, and incurable diseases characterized by the gradual loss of neurons, culminating in the decline of cognitive and/or motor functions. Alzheimer's disease (AD) and Parkinson's disease (PD) are the most common NDs and represent an enormous burden both in terms of human suffering and economic cost. The available therapies for AD and PD only provide symptomatic and palliative relief for a limited period and are unable to modify the diseases' progression. Over the last decades, research efforts have been focused on developing new pharmacological treatments for these NDs. However, to date, no breakthrough treatment has been discovered. Hence, the development of disease-modifying drugs able to halt or reverse the progression of NDs remains an unmet clinical need. This review summarizes the major hallmarks of AD and PD and the drugs available for pharmacological treatment. It also sheds light on potential directions that can be pursued to develop new, disease-modifying drugs to treat AD and PD, describing as representative examples some advances in the development of drug candidates targeting oxidative stress and adenosine A2A receptors.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Fernanda Borges
- CIQUP-IMS—Centro de Investigação em Química da Universidade do Porto, Institute of Molecular Sciences, Department of Chemistry and Biochemistry, Faculty of Sciences, University of Porto, R. Campo Alegre s/n, 4169-007 Porto, Portugal
| | - Daniel Chavarria
- CIQUP-IMS—Centro de Investigação em Química da Universidade do Porto, Institute of Molecular Sciences, Department of Chemistry and Biochemistry, Faculty of Sciences, University of Porto, R. Campo Alegre s/n, 4169-007 Porto, Portugal
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Shukla H, John D, Banerjee S, Tiwari AK. Drug repurposing for neurodegenerative diseases. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2024; 207:249-319. [PMID: 38942541 DOI: 10.1016/bs.pmbts.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Neurodegenerative diseases (NDDs) are neuronal problems that include the brain and spinal cord and result in loss of sensory and motor dysfunction. Common NDDs include Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease (HD), Multiple Sclerosis (MS), and Amyotrophic Lateral Sclerosis (ALS) etc. The occurrence of these diseases increases with age and is one of the challenging problems among elderly people. Though, several scientific research has demonstrated the key pathologies associated with NDDs still the underlying mechanisms and molecular details are not well understood and need to be explored and this poses a lack of effective treatments for NDDs. Several lines of evidence have shown that NDDs have a high prevalence and affect more than a billion individuals globally but still, researchers need to work forward in identifying the best therapeutic target for NDDs. Thus, several researchers are working in the directions to find potential therapeutic targets to alter the disease pathology and treat the diseases. Several steps have been taken to identify the early detection of the disease and drug repurposing for effective treatment of NDDs. Moreover, it is logical that current medications are being evaluated for their efficacy in treating such disorders; therefore, drug repurposing would be an efficient, safe, and cost-effective way in finding out better medication. In the current manuscript we discussed the utilization of drugs that have been repurposed for the treatment of AD, PD, HD, MS, and ALS.
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Affiliation(s)
- Halak Shukla
- Department of Biotechnology and Bioengineering, Institute of Advanced Research (IAR), Gandhinagar, Gujarat, India
| | - Diana John
- Department of Biotechnology and Bioengineering, Institute of Advanced Research (IAR), Gandhinagar, Gujarat, India
| | - Shuvomoy Banerjee
- Department of Biotechnology and Bioengineering, Institute of Advanced Research (IAR), Gandhinagar, Gujarat, India
| | - Anand Krishna Tiwari
- Genetics and Developmental Biology Laboratory, Department of Biotechnology and Bioengineering, Institute of Advanced Research (IAR), Gandhinagar, Gujarat, India.
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Li J, Haj Ebrahimi A, Ali AB. Advances in Therapeutics to Alleviate Cognitive Decline and Neuropsychiatric Symptoms of Alzheimer's Disease. Int J Mol Sci 2024; 25:5169. [PMID: 38791206 PMCID: PMC11121252 DOI: 10.3390/ijms25105169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Dementia exists as a 'progressive clinical syndrome of deteriorating mental function significant enough to interfere with activities of daily living', with the most prevalent type of dementia being Alzheimer's disease (AD), accounting for about 80% of diagnosed cases. AD is associated with an increased risk of comorbidity with other clinical conditions such as hypertension, diabetes, and neuropsychiatric symptoms (NPS) including, agitation, anxiety, and depression as well as increased mortality in late life. For example, up to 70% of patients diagnosed with AD are affected by anxiety. As aging is the major risk factor for AD, this represents a huge global burden in ageing populations. Over the last 10 years, significant efforts have been made to recognize the complexity of AD and understand the aetiology and pathophysiology of the disease as well as biomarkers for early detection. Yet, earlier treatment options, including acetylcholinesterase inhibitors and glutamate receptor regulators, have been limited as they work by targeting the symptoms, with only the more recent FDA-approved drugs being designed to target amyloid-β protein with the aim of slowing down the progression of the disease. However, these drugs may only help temporarily, cannot stop or reverse the disease, and do not act by reducing NPS associated with AD. The first-line treatment options for the management of NPS are selective serotonin reuptake inhibitors/selective noradrenaline reuptake inhibitors (SSRIs/SNRIs) targeting the monoaminergic system; however, they are not rational drug choices for the management of anxiety disorders since the GABAergic system has a prominent role in their development. Considering the overall treatment failures and side effects of currently available medication, there is an unmet clinical need for rationally designed therapies for anxiety disorders associated with AD. In this review, we summarize the current status of the therapy of AD and aim to highlight novel angles for future drug therapy in our ongoing efforts to alleviate the cognitive deficits and NPS associated with this devastating disease.
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Affiliation(s)
| | | | - Afia B. Ali
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK; (J.L.); (A.H.E.)
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Chen Y, Lai M, Tao M. Evaluating the efficacy and safety of Alzheimer's disease drugs: A meta-analysis and systematic review. Medicine (Baltimore) 2024; 103:e37799. [PMID: 38640313 PMCID: PMC11029996 DOI: 10.1097/md.0000000000037799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/07/2024] [Accepted: 03/14/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Alzheimer's disease (AD) is a progressive neurodegenerative disorder. Dementia severity was assessed mainly through cognitive function, psychobehavioral symptoms, and daily living ability. Currently, there are not many drugs that can be selected to treat mild to moderate AD, and the value of drugs remains controversial. OBJECTIVE The aim of this study is to quantitatively evaluate the efficacy and safety of cholinesterase inhibitors (ChEIs), memantine, and sodium oligomannate (GV-971) in the treatment of patients with AD. Additionally, molecular docking analysis will be used to investigate the binding affinities of donepezil, galantamine, rivastigmine, and memantine with key receptor proteins associated with AD, including beta-amyloid (Abeta), microtubule-associated protein (MAP), apolipoprotein E4 (APOE4), and Mitofusin-2 (MFN2), to further validate the results of the meta-analysis. METHODS We obtained clinical trials characterized by randomization, placebo control, and double-blinded methodologies concerning ChEIs, memantine, and GV-971. Statistical analysis was performed using Review Manager Version 5.4 software. Molecular docking was also conducted to evaluate the results. RESULTS All drugs improved the cognitive function, with the effect value ranging from -1.23 (95% CI -2.17 to -0.30) for 20 mg memantine to -3.29 (95% CI -4.14 to -2.45) for 32 mg galantamine. Although 32 mg galanthamine and GV-971 did not improve the clinicians' Global Impression of Change scale, other drugs showed significant results compared with placebo. On NPI, only 10 mg of donepezil and 24 mg of galantamine had improvement effects. On ADCS/ADL, only 20 mg memantine and 900 mg GV-971 had no significant difference from the placebo. Donepezil 5 mg and GV-971 900 mg did not increase the drug withdrawal rates due to various reasons or adverse reactions when compared to the placebo. Donepezil demonstrated superior binding to the protein and exhibited greater efficacy compared to other drugs. CONCLUSION ChEIs, memantine, and GV-971 all can slow the progression of AD but have different effects on respective assessments. Donepezil and GV-971 were relatively well tolerated.
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Affiliation(s)
- Yan Chen
- The Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Min Lai
- The Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Ming Tao
- The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
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Luo Z, Yin F, Wang X, Kong L. Progress in approved drugs from natural product resources. Chin J Nat Med 2024; 22:195-211. [PMID: 38553188 DOI: 10.1016/s1875-5364(24)60582-0] [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: 12/03/2023] [Indexed: 04/02/2024]
Abstract
Natural products (NPs) have consistently played a pivotal role in pharmaceutical research, exerting profound impacts on the treatment of human diseases. A significant proportion of approved molecular entity drugs are either directly derived from NPs or indirectly through modifications of NPs. This review presents an overview of NP drugs recently approved in China, the United States, and other countries, spanning various disease categories, including cancers, cardiovascular and cerebrovascular diseases, central nervous system disorders, and infectious diseases. The article provides a succinct introduction to the origin, activity, development process, approval details, and mechanism of action of these NP drugs.
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Affiliation(s)
- Zhongwen Luo
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Bioactive Natural Product Research, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Fucheng Yin
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Bioactive Natural Product Research, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Xiaobing Wang
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Bioactive Natural Product Research, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Lingyi Kong
- State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Bioactive Natural Product Research, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing 211198, China.
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Bermejo-Pareja F, del Ser T. Controversial Past, Splendid Present, Unpredictable Future: A Brief Review of Alzheimer Disease History. J Clin Med 2024; 13:536. [PMID: 38256670 PMCID: PMC10816332 DOI: 10.3390/jcm13020536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
Background: The concept of Alzheimer disease (AD)-since its histological discovery by Alzheimer to the present day-has undergone substantial modifications. Methods: We conducted a classical narrative review of this field with a bibliography selection (giving preference to Medline best match). Results: The following subjects are reviewed and discussed: Alzheimer's discovery, Kraepelin's creation of a new disease that was a rare condition until the 1970's, the growing interest and investment in AD as a major killer in a society with a large elderly population in the second half of the 20th century, the consolidation of the AD clinicopathological model, and the modern AD nosology based on the dominant amyloid hypothesis among many others. In the 21st century, the development of AD biomarkers has supported a novel biological definition of AD, although the proposed therapies have failed to cure this disease. The incidence of dementia/AD has shown a decrease in affluent countries (possibly due to control of risk factors), and mixed dementia has been established as the most frequent etiology in the oldest old. Conclusions: The current concept of AD lacks unanimity. Many hypotheses attempt to explain its complex physiopathology entwined with aging, and the dominant amyloid cascade has yielded poor therapeutic results. The reduction in the incidence of dementia/AD appears promising but it should be confirmed in the future. A reevaluation of the AD concept is also necessary.
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Affiliation(s)
- Félix Bermejo-Pareja
- CIBERNED, Institute of Health Carlos III, 28029 Madrid, Spain
- Institute of Research i+12, University Hospital “12 de Octubre”, 28041 Madrid, Spain
| | - Teodoro del Ser
- Alzheimer’s Centre Reina Sofia—CIEN Foundation, Institute of Health Carlos III, 28031 Madrid, Spain;
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Ji X, Peng X, Tang H, Pan H, Wang W, Wu J, Chen J, Wei N. Alzheimer's disease phenotype based upon the carrier status of the apolipoprotein E ɛ4 allele. Brain Pathol 2024; 34:e13208. [PMID: 37646624 PMCID: PMC10711266 DOI: 10.1111/bpa.13208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 08/05/2023] [Indexed: 09/01/2023] Open
Abstract
The apolipoprotein E ɛ4 allele (APOE4) is universally acknowledged as the most potent genetic risk factor for Alzheimer's disease (AD). APOE4 promotes the initiation and progression of AD. Although the underlying mechanisms are unclearly understood, differences in lipid-bound affinity among the three APOE isoforms may constitute the basis. The protein APOE4 isoform has a high affinity with triglycerides and cholesterol. A distinction in lipid metabolism extensively impacts neurons, microglia, and astrocytes. APOE4 carriers exhibit phenotypic differences from non-carriers in clinical examinations and respond differently to multiple treatments. Therefore, we hypothesized that phenotypic classification of AD patients according to the status of APOE4 carrier will help specify research and promote its use in diagnosing and treating AD. Recent reviews have mainly evaluated the differences between APOE4 allele carriers and non-carriers from gene to protein structures, clinical features, neuroimaging, pathology, the neural network, and the response to various treatments, and have provided the feasibility of phenotypic group classification based on APOE4 carrier status. This review will facilitate the application of APOE phenomics concept in clinical practice and promote further medical research on AD.
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Affiliation(s)
- Xiao‐Yu Ji
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
- Brain Function and Disease LaboratoryShantou University Medical CollegeGuangdongChina
| | - Xin‐Yuan Peng
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
| | - Hai‐Liang Tang
- Fudan University Huashan Hospital, Department of Neurosurgery, State Key Laboratory for Medical NeurobiologyInstitutes of Brain Science, Shanghai Medical College‐Fudan UniversityShanghaiChina
| | - Hui Pan
- Shantou Longhu People's HospitalShantouGuangdongChina
| | - Wei‐Tang Wang
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
| | - Jie Wu
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
- Brain Function and Disease LaboratoryShantou University Medical CollegeGuangdongChina
| | - Jian Chen
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
| | - Nai‐Li Wei
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
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Ahuja M, Siddhpuria S, Karimi A, Lewis K, Wong E, Lee J, Reppas-Rindlisbacher C, Sood E, Gabor C, Patterson C. Cholinesterase inhibitors and falls, syncope and injuries in patients with cognitive impairment: a systematic review and meta-analysis. Age Ageing 2023; 52:afad205. [PMID: 37993407 DOI: 10.1093/ageing/afad205] [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: 05/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Cholinesterase inhibitors are commonly used to treat patients with neurocognitive disorders, who often have an elevated risk of falling. Effective use of these medications requires a thoughtful assessment of risks and benefits. OBJECTIVE To provide an update on previous reviews and determine the association between cholinesterase inhibitors and falls, syncope, fracture and accidental injuries in patients with neurocognitive disorders. METHODS Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature and AgeLine were systematically searched through March 2023 to identify all randomised controlled trials of cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in patients with cognitive impairment. Corresponding authors were contacted for additional data necessary for meta-analysis. Inclusion criteria consisted of adults ≥19 years, with a diagnosis of dementia, Parkinson's disease, mild cognitive impairment or traumatic brain injury. Data were extracted in duplicate for the aforementioned primary outcomes and all outcomes were analysed using random-effects meta-analysis. RESULTS Fifty three studies (30 donepezil, 14 galantamine, 9 rivastigmine) were included providing data on 25, 399 patients. Cholinesterase inhibitors, compared to placebo, were associated with reduced risk of falls (risk ratio [RR] 0.84 [95% confidence interval [CI] = 0.73-0.96, P = 0.009]) and increased risk of syncope (RR 1.50 [95% CI = 1.02-2.21, P = 0.04]). There was no association with accidental injuries or fractures. CONCLUSION In patients with neurocognitive disorders, cholinesterase inhibitors were associated with decreased risk of falls, increased risk of syncope and no association with accidental trauma or fractures. These findings will help clinicians better evaluate risks and benefits of cholinesterase inhibitors.
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Affiliation(s)
- Manan Ahuja
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shailee Siddhpuria
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arian Karimi
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Kaitlin Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Eric Wong
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Justin Lee
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Emma Sood
- Faculty of Science, Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Ontario, Canada
| | | | - Christopher Patterson
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Canada
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Naser SS, Singh D, Preetam S, Kishore S, Kumar L, Nandi A, Simnani FZ, Choudhury A, Sinha A, Mishra YK, Suar M, Panda PK, Malik S, Verma SK. Posterity of nanoscience as lipid nanosystems for Alzheimer's disease regression. Mater Today Bio 2023; 21:100701. [PMID: 37415846 PMCID: PMC10320624 DOI: 10.1016/j.mtbio.2023.100701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 07/08/2023] Open
Abstract
Alzheimer's disease (AD) is a type of dementia that affects a vast number of people around the world, causing a great deal of misery and death. Evidence reveals a relationship between the presence of soluble Aβ peptide aggregates and the severity of dementia in Alzheimer's patients. The BBB (Blood Brain Barrier) is a key problem in Alzheimer's disease because it prevents therapeutics from reaching the desired places. To address the issue, lipid nanosystems have been employed to deliver therapeutic chemicals for anti-AD therapy in a precise and targeted manner. The applicability and clinical significance of lipid nanosystems to deliver therapeutic chemicals (Galantamine, Nicotinamide, Quercetin, Resveratrol, Curcumin, HUPA, Rapamycin, and Ibuprofen) for anti-AD therapy will be discussed in this review. Furthermore, the clinical implications of the aforementioned therapeutic compounds for anti-AD treatment have been examined. Thus, this review will pave the way for researchers to fashion therodiagnostics approaches based on nanomedicine to overcome the problems of delivering therapeutic molecules across the blood brain barrier (BBB).
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Affiliation(s)
- Shaikh Sheeran Naser
- KIIT School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT-DU), Bhubaneswar 751024, Odisha, India
| | - Dibyangshee Singh
- KIIT School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT-DU), Bhubaneswar 751024, Odisha, India
| | - Subham Preetam
- Institute of Advanced Materials, IAAM, Gammalkilsvägen 18, 59053 Ulrika, Sweden
| | - Shristi Kishore
- Amity Institute of Biotechnology, Amity University Jharkhand, Ranchi, Jharkhand 834001, India
| | - Lamha Kumar
- School of Biology, Indian Institute of Science Education and Research, Thiruvananthapuram, Kerala 695551, India
| | - Aditya Nandi
- KIIT School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT-DU), Bhubaneswar 751024, Odisha, India
| | - Faizan Zarreen Simnani
- KIIT School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT-DU), Bhubaneswar 751024, Odisha, India
| | - Anmol Choudhury
- KIIT School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT-DU), Bhubaneswar 751024, Odisha, India
| | - Adrija Sinha
- KIIT School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT-DU), Bhubaneswar 751024, Odisha, India
| | - Yogendra Kumar Mishra
- Mads Clausen Institute, NanoSYD, University of Southern Denmark, Alison 2, 6400 Sønderborg, Denmark
| | - Mrutyunjay Suar
- KIIT School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT-DU), Bhubaneswar 751024, Odisha, India
| | - Pritam Kumar Panda
- Department of Physics and Astronomy, Uppsala University, Box 516, SE-75120 Uppsala, Sweden
| | - Sumira Malik
- School of Biology, Indian Institute of Science Education and Research, Thiruvananthapuram, Kerala 695551, India
| | - Suresh K. Verma
- KIIT School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT-DU), Bhubaneswar 751024, Odisha, India
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Dávila G, Torres-Prioris MJ, López-Barroso D, Berthier ML. Turning the Spotlight to Cholinergic Pharmacotherapy of the Human Language System. CNS Drugs 2023; 37:599-637. [PMID: 37341896 PMCID: PMC10374790 DOI: 10.1007/s40263-023-01017-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/22/2023]
Abstract
Even though language is essential in human communication, research on pharmacological therapies for language deficits in highly prevalent neurodegenerative and vascular brain diseases has received little attention. Emerging scientific evidence suggests that disruption of the cholinergic system may play an essential role in language deficits associated with Alzheimer's disease and vascular cognitive impairment, including post-stroke aphasia. Therefore, current models of cognitive processing are beginning to appraise the implications of the brain modulator acetylcholine in human language functions. Future work should be directed further to analyze the interplay between the cholinergic system and language, focusing on identifying brain regions receiving cholinergic innervation susceptible to modulation with pharmacotherapy to improve affected language domains. The evaluation of language deficits in pharmacological cholinergic trials for Alzheimer's disease and vascular cognitive impairment has thus far been limited to coarse-grained methods. More precise, fine-grained language testing is needed to refine patient selection for pharmacotherapy to detect subtle deficits in the initial phases of cognitive decline. Additionally, noninvasive biomarkers can help identify cholinergic depletion. However, despite the investigation of cholinergic treatment for language deficits in Alzheimer's disease and vascular cognitive impairment, data on its effectiveness are insufficient and controversial. In the case of post-stroke aphasia, cholinergic agents are showing promise, particularly when combined with speech-language therapy to promote trained-dependent neural plasticity. Future research should explore the potential benefits of cholinergic pharmacotherapy in language deficits and investigate optimal strategies for combining these agents with other therapeutic approaches.
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Affiliation(s)
- Guadalupe Dávila
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Marqués de Beccaria 3, 29010, Malaga, Spain
- Instituto de Investigación Biomédica de Malaga-IBIMA, Malaga, Spain
- Department of Psychobiology and Methodology of Behavioral Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
- Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - María José Torres-Prioris
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Marqués de Beccaria 3, 29010, Malaga, Spain
- Instituto de Investigación Biomédica de Malaga-IBIMA, Malaga, Spain
- Department of Psychobiology and Methodology of Behavioral Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
- Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - Diana López-Barroso
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Marqués de Beccaria 3, 29010, Malaga, Spain
- Instituto de Investigación Biomédica de Malaga-IBIMA, Malaga, Spain
- Department of Psychobiology and Methodology of Behavioral Sciences, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
- Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain
| | - Marcelo L Berthier
- Cognitive Neurology and Aphasia Unit, Centro de Investigaciones Médico-Sanitarias, University of Malaga, Marqués de Beccaria 3, 29010, Malaga, Spain.
- Instituto de Investigación Biomédica de Malaga-IBIMA, Malaga, Spain.
- Language Neuroscience Research Laboratory, Faculty of Psychology and Speech Therapy, University of Malaga, Malaga, Spain.
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13
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Babashpour-Asl M, kaboudi PS, Barez SR. Therapeutic and medicinal effects of snowdrop ( Galanthus spp.) in Alzheimer's disease: A review. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:128. [PMID: 37397105 PMCID: PMC10312406 DOI: 10.4103/jehp.jehp_451_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 08/13/2022] [Indexed: 07/04/2023]
Abstract
Genus Galanthus (Amaryllidaceae) is an early spring flowering bulbous plant. Galanthus species contain alkaloids that have shown pharmacological activity. Galanthamine is an alkaloid that was extracted from Galanthus and other Amaryllidaceae. Owing to its acetylcholinesterase (AChE) inhibitory activity, galanthamine is used and marketed to treat Alzheimer's disease (AD). The aim of the present study, while introducing the botanical and pharmacological characteristics and various aspects of the medicinal plant Galanthus, is to emphasize the effect of this plant in the treatment of AD. In this web-based study in 2021, articles indexed in scientific databases in English language, including ISI Web of Knowledge, PubMed, Scopus, MedLib, Medknow, SID, ISC, and also articles and e-books published in Springer, Elsevier, John Wiley and Sons, and Taylor and Francis were evaluated from 1990 to 2021, using the following keywords: "Galanthus" "galanthamine," "Alzheimer's disease." Amaryllidaceae-type alkaloids possess an anticholinesterase activity. The most studied Galanthus alkaloid, galanthamine, is a long-acting, selective, reversible, competitive inhibitor of AChE and an allosteric modulator of the neuronal nicotinic receptor for acetylcholine (ACh). Owing to its AChE inhibitory activity, galanthamine is used to treat certain stages of AD. Galantamine can act as a parasympathomimetic agent, especially as a reversible cholinesterase inhibitor. Galantamine is not structurally associated with other AChE inhibitors. Hence, its proposed mechanism of action involves the reversible inhibition of AChE, preventing hydrolysis of ACh that results in an increased concentration of ACh at cholinergic synapses.
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Affiliation(s)
- Marzieh Babashpour-Asl
- Department of Horticultural Science, Maragheh Branch, Islamic Azad University, Maragheh, Iran
| | | | - Shekufe Rezghi Barez
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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14
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A Review on Phyto-Therapeutic Approaches in Alzheimer's Disease. J Funct Biomater 2023; 14:jfb14010050. [PMID: 36662097 PMCID: PMC9861153 DOI: 10.3390/jfb14010050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/29/2022] [Accepted: 01/14/2023] [Indexed: 01/19/2023] Open
Abstract
Neurodegenerative diseases occur due to progressive and sometimes irreversible loss of function and death of nerve cells. A great deal of effort is being made to understand the pathogenesis of neurodegenerative diseases. In particular, the prevalence of Alzheimer's disease (AD) is quite high, and only symptomatic therapy is available due to the absence of radical treatment. The aim of this review is to try to elucidate the general pathogenesis of AD, to provide information about the limit points of symptomatic treatment approaches, and to emphasize the potential neurologic effects of phytocompounds as new tools as therapeutic agents for disease prevention, retardation, and therapy. This survey also covers the notable properties of herbal compounds such as their effects on the inhibition of an enzyme called acetylcholinesterase, which has significant value in the treatment of AD. It has been proven that phytopharmaceuticals have long-term effects that could protect nervous system health, eliminate inflammatory responses, improve cognitive damage, provide anti-aging effects in the natural aging process, and alleviate dementia sequelae. Herbal-based therapeutic agents can afford many advantages and can be used as potentially as new-generation therapeutics or complementary agents with high compliance, fewer adverse effects, and lower cost in comparison to the traditional pharmaceutical agents in the fight against AD.
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15
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Shegani A, Kealey S, Luzi F, Basagni F, Machado JDM, Ekici SD, Ferocino A, Gee AD, Bongarzone S. Radiosynthesis, Preclinical, and Clinical Positron Emission Tomography Studies of Carbon-11 Labeled Endogenous and Natural Exogenous Compounds. Chem Rev 2023; 123:105-229. [PMID: 36399832 PMCID: PMC9837829 DOI: 10.1021/acs.chemrev.2c00398] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Indexed: 11/19/2022]
Abstract
The presence of positron emission tomography (PET) centers at most major hospitals worldwide, along with the improvement of PET scanner sensitivity and the introduction of total body PET systems, has increased the interest in the PET tracer development using the short-lived radionuclides carbon-11. In the last few decades, methodological improvements and fully automated modules have allowed the development of carbon-11 tracers for clinical use. Radiolabeling natural compounds with carbon-11 by substituting one of the backbone carbons with the radionuclide has provided important information on the biochemistry of the authentic compounds and increased the understanding of their in vivo behavior in healthy and diseased states. The number of endogenous and natural compounds essential for human life is staggering, ranging from simple alcohols to vitamins and peptides. This review collates all the carbon-11 radiolabeled endogenous and natural exogenous compounds synthesised to date, including essential information on their radiochemistry methodologies and preclinical and clinical studies in healthy subjects.
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Affiliation(s)
- Antonio Shegani
- School
of Biomedical Engineering & Imaging Sciences, King’s College London, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Steven Kealey
- School
of Biomedical Engineering & Imaging Sciences, King’s College London, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Federico Luzi
- School
of Biomedical Engineering & Imaging Sciences, King’s College London, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Filippo Basagni
- Department
of Pharmacy and Biotechnology, Alma Mater
Studiorum−University of Bologna, via Belmeloro 6, 40126 Bologna, Italy
| | - Joana do Mar Machado
- School
of Biomedical Engineering & Imaging Sciences, King’s College London, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Sevban Doğan Ekici
- School
of Biomedical Engineering & Imaging Sciences, King’s College London, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Alessandra Ferocino
- Institute
of Organic Synthesis and Photoreactivity, Italian National Research Council, via Piero Gobetti 101, 40129 Bologna, Italy
| | - Antony D. Gee
- School
of Biomedical Engineering & Imaging Sciences, King’s College London, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Salvatore Bongarzone
- School
of Biomedical Engineering & Imaging Sciences, King’s College London, King’s Health Partners, St Thomas’ Hospital, London SE1 7EH, United Kingdom
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16
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Koulousakis P, Willems E, Schepers M, Rombaut B, Prickaerts J, Vanmierlo T, van den Hove D. Exogenous Oxytocin Administration Restores Memory in Female APP/PS1 Mice. J Alzheimers Dis 2023; 96:1207-1219. [PMID: 37927260 PMCID: PMC10741313 DOI: 10.3233/jad-230657] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Current treatment options for Alzheimer's disease (AD) are limited, inefficient, and often have serious side effects. Oxytocin is a neuropeptide implicated in a variety of central processes, such as social and reproductive behaviors. Among others, it has garnered attention in various domains of psychiatric research, while its role in the development and course of neurodegenerative disorders like AD is rather unknown. OBJECTIVE This study aimed to investigate the role of exogenous oxytocin administration on memory, specifically in view of AD, as a potential novel treatment option. METHODS We describe a novel treatment approach by using a relatively low dose of long-term intranasal oxytocin treatment, to restore memory deficits in female APPswePS1dE9 mice. RESULTS Female APPswePS1dE9 mice treated with oxytocin showed increased spatial memory performance in the object location task and improved working memory in the Y-Maze, while indicating decreased sociability. CONCLUSIONS These results indicate that oxytocin is able to reverse acquired cognitive deficits in female APPswePS1dE9 mice.
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Affiliation(s)
- Philippos Koulousakis
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Emily Willems
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Melissa Schepers
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Ben Rombaut
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Jos Prickaerts
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Tim Vanmierlo
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Daniel van den Hove
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
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Ajenikoko MK, Ajagbe AO, Onigbinde OA, Okesina AA, Tijani AA. Review of Alzheimer's disease drugs and their relationship with neuron-glia interaction. IBRO Neurosci Rep 2022; 14:64-76. [PMID: 36593897 PMCID: PMC9803919 DOI: 10.1016/j.ibneur.2022.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022] Open
Abstract
Alzheimer's disease (AD) is the most common cause of dementia worldwide. Because Alzheimer's disease has no known treatment, sufferers and their caregivers must concentrate on symptom management. Astrocytes and microglia are now known to play distinct physiological roles in synaptic function, the blood-brain barrier, and neurovascular coupling. Consequently, the search for drugs that can slow the degenerative process in dementia sufferers continues because existing drugs are designed to alleviate the symptoms of Alzheimer's disease. Drugs that address pathological changes without interfering with the normal function of glia, such as eliminating amyloid-beta deposits, are prospective treatments for neuroinflammatory illnesses. Because neuron-astrocytes-microglia interactions are so complex, developing effective, preventive, and therapeutic medications for AD will necessitate novel methodologies and strategic targets. This review focused on existing medications used in treating AD amongst which include Donepezil, Choline Alphoscerate, Galantamine, Dextromethorphan, palmitoylethanolamide, citalopram, resveratrol, and solanezumab. This review summarizes the effects of these drugs on neurons, astrocytes, and microglia interactions based on their pharmacokinetic properties, mechanism of action, dosing, and clinical presentations.
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Affiliation(s)
- Michael Kunle Ajenikoko
- Department of Anatomy, Faculty of Biomedical Sciences, Kampala International University, Western Campus, Ishaka, Uganda,Correspondence to: Department of Anatomy, Faculty of Biomedical Sciences, Kampala International University, Western Campus, Uganda.
| | - Abayomi Oyeyemi Ajagbe
- Department of Anatomy, Faculty of Basic Medical Sciences, College of Health Sciences, Nile University of Nigeria, P.M.B. 900001 Abuja, Nigeria
| | - Oluwanisola Akanji Onigbinde
- Department of Anatomy, Faculty of Basic Medical Sciences, College of Health Sciences, Nile University of Nigeria, P.M.B. 900001 Abuja, Nigeria
| | - Akeem Ayodeji Okesina
- Department of Clinical Medicine and Community Health, School of Health Sciences, College of Medicine and Health Sciences, University of Rwanda, Rwanda
| | - Ahmad Adekilekun Tijani
- Department of Anatomy, Faculty of Basic Medical Sciences, Modibbo Adama University, Yola, Nigeria
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18
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Yaowaluk T, Senanarong V, Limwongse C, Boonprasert R, Bunditvorapoom D, Kaewsutthi S, Kijsanayotin P. Association study identifies genetic determinants and non-genetic factors on steady-state plasma and therapeutic outcome of galantamine in mixed dementia. Eur J Clin Pharmacol 2022; 78:1249-1259. [PMID: 35633386 DOI: 10.1007/s00228-022-03322-1] [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: 06/11/2021] [Accepted: 04/15/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE This study aimed to evaluate the influence of genetic polymorphisms of drug-metabolizing enzyme genes, transporter gene, pathological gene (APOE), and non-genetic factors on therapeutic outcomes as well as steady-state plasma concentrations (Cpss) of galantamine in Thai patients with mixed dementia. METHODS Fifty-one Thai patients with mixed dementia who received galantamine for at least 6 months were recruited. CYP2D6, CYP3A5, and ABCB1 polymorphisms were detected by TaqMan® Genotyping Assay. UGT1A1 and APOE polymorphism was detected by direct Sanger sequencing technique and restriction fragment length polymorphism technique. Cpss of galantamine was measured by ultra-performance liquid chromatography. Associations of genetic and non-genetic factors with Cpss and clinical outcomes (change in cognitive function as measured by the Thai Mental State Examination (ΔTMSE) scores) were determined by using univariate and multivariate analysis. RESULTS The multivariate regression model revealed that patients who carried one or more detrimental allelic variant (CYP2D6, CYP3A5, and UGT1A1) showed a tendency toward a higher galantamine adjusted Cpss (B = 34.559, 95% CI = 0.741-68.377, p value = 0.045). Logistic regression analysis also revealed CYP2D6*10 carriers were significantly associated with higher ΔTMSE (B = 5.227, 95% CI = 2.395-8.060, p value = 0.001). UGT1A1 mutant alleles and non-genetic factors including concomitant use of statin drugs and higher education level can attenuate therapeutic outcomes of galantamine. CONCLUSION Pharmacokinetic-related genes including CYP2D6*10 and UGT1A1 mutant alleles were significantly associated with galantamine adjusted Cpss and cognitive function. Determination of Cpss and genotype could be an adjunct examination to provide further explanation in interindividual variability of galantamine therapeutic outcome.
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Affiliation(s)
- Thitipon Yaowaluk
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Phayathai Rd, Pathumwan, Bangkok, 10330, Thailand
| | - Vorapun Senanarong
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanin Limwongse
- Division of Medical Genetics, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rasda Boonprasert
- Clinical Toxicology Laboratory, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Duangkamon Bunditvorapoom
- Division of Medical Genetics, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supannee Kaewsutthi
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pornpimol Kijsanayotin
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Phayathai Rd, Pathumwan, Bangkok, 10330, Thailand.
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19
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Bloom O, Tracey KJ, Pavlov VA. Exploring the vagus nerve and the inflammatory reflex for therapeutic benefit in chronic spinal cord injury. Curr Opin Neurol 2022; 35:249-257. [PMID: 35102123 PMCID: PMC9258775 DOI: 10.1097/wco.0000000000001036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe features and implications of chronic systemic inflammation in individuals with spinal cord injury (SCI) and to summarize the growing therapeutic possibilities to explore the vagus nerve-mediated inflammatory reflex in this context. RECENT FINDINGS The discovery of the inflammatory reflex provides a rationale to explore neuromodulation modalities, that is, electrical vagus nerve stimulation and pharmacological cholinergic modalities to regulate inflammation after SCI. SUMMARY Inflammation in individuals with SCI may negatively impact functional recovery and medical consequences after SCI. Exploring the potential of the vagus nerve-based inflammatory reflex to restore autonomic regulation and control inflammation may provide a novel approach for functional improvement in SCI.
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Affiliation(s)
- Ona Bloom
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset
- Donald and Barbara Zucker School of Medicine, Hempstead, New York, USA
| | - Kevin J. Tracey
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset
- Donald and Barbara Zucker School of Medicine, Hempstead, New York, USA
| | - Valentin A. Pavlov
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset
- Donald and Barbara Zucker School of Medicine, Hempstead, New York, USA
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20
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Florentino SA, Bawany MH, Ma HM. Acetylcholinesterase inhibitors to enhance recovery from traumatic brain injury: a comprehensive review and case series. Brain Inj 2022; 36:441-454. [PMID: 35113764 DOI: 10.1080/02699052.2022.2034962] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Acetylcholinesterase inhibitors (AChEIs) are used off-label, in both adult and pediatric patients, to help further neuro-recovery after traumatic brain injury (TBI). Evidence is limited and piecemeal. This review describes how TBI affects the cholinergic system and consolidates evidence supporting or refuting the use of AChEIs following TBI. METHODS NCBI MEDLINE search included all articles published through March 2021 on AChEI use in acute and post-acute adult TBI rehabilitation (treatment began <90 days or ≥90 days since injury, respectively), and in pediatric TBI rehabilitation. Further, we checked ClinicalTrials.gov for ongoing trials using AChEIs for TBI rehabilitation in the United States. RESULTS 27 original articles from NCBI Medline, published through March 2021, were included. The use of AChEIs following TBI in acute and post-acute rehabilitation settings, in both adult and pediatric patients, along with medication side effects, is discussed. CONCLUSIONS Most studies showed benefits with only moderate effect sizes because of small sample sizes. Reported side effects are minimal and stop soon after AChEIs is discontinued. Conclusions are limited by paucity of research; but fortunately, a large randomized controlled trial is ongoing, and more are needed to truly determine the efficacy of AChEIs in helping with recovery from TBI.
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Affiliation(s)
- Samuel A Florentino
- School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Mohammad H Bawany
- Department of Emergency Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Heather M Ma
- Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
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21
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Tseng PT, Zeng BY, Chen YW, Yang CP, Su KP, Chen TY, Wu YC, Tu YK, Lin PY, Carvalho AF, Stubbs B, Matsuoka YJ, Li DJ, Liang CS, Hsu CW, Sun CK, Cheng YS, Yeh PY, Shiue YL. The Dose and Duration-dependent Association between Melatonin Treatment and Overall Cognition in Alzheimer's Dementia: A Network Meta- Analysis of Randomized Placebo-Controlled Trials. Curr Neuropharmacol 2022; 20:1816-1833. [PMID: 35450525 PMCID: PMC9886806 DOI: 10.2174/1570159x20666220420122322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 02/18/2022] [Accepted: 04/14/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND While Alzheimer's dementia (AD) has a prevalence as high as 3-32% and is associated with cognitive dysfunction and the risk of institutionalization, no efficacious and acceptable treatments can modify the course of cognitive decline in AD. Potential benefits of exogenous melatonin for cognition have been divergent across trials. OBJECTIVE The current network meta-analysis (NMA) was conducted under the frequentist model to evaluate the potential beneficial effects of exogenous melatonin supplementation on overall cognitive function in participants with AD in comparison to other FDA-approved medications (donepezil, galantamine, rivastigmine, memantine, and Namzaric). METHODS The primary outcome was the changes in the cognitive function [measured by mini-mental state examination (MMSE)] after treatment in patients with Alzheimer's dementia. The secondary outcomes were changes in the quality of life, behavioral disturbance, and acceptability (i.e., drop-out due to any reason and rate of any adverse event reported). RESULTS The current NMA of 50 randomized placebo-controlled trials (RCTs) revealed the medium-term lowdose melatonin to be associated with the highest post-treatment MMSE (mean difference = 1.48 in MMSE score, 95% confidence intervals [95% CIs] = 0.51 to 2.46) and quality of life (standardized mean difference = -0.64, 95% CIs = -1.13 to -0.15) among all of the investigated medications in the participants with AD. Finally, all of the investigated exogenous melatonin supplements were associated with similar acceptability as was the placebo. CONCLUSION The current NMA provides evidence for the potential benefits of exogenous melatonin supplementation, especially medium-term low-dose melatonin, in participants with AD.
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Affiliation(s)
- Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan; Clinical Psychology Center, Asia University Hospital, Taichung, Taiwan
| | - Bing-Yan Zeng
- Department of Internal Medicine, E-DA Dachang Hospital, Kaohsiung, Taiwan
| | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Nutrition, Huangkuang University, Taichung, Taiwan
| | - Kuan-Pin Su
- Department of Psychiatry & Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
- An-Nan Hospital, China Medical University, Tainan, Taiwan
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei112, Taiwan
| | - Yi-Cheng Wu
- Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Andre F. Carvalho
- Innovation in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Faculty of Health, Social Care Medicine and Education, Anglia Ruskin University, Chelmsford, UK
| | - Yutaka J. Matsuoka
- Department of Psychiatry & Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan
- Former Division Chief of Health Care Research, National Cancer Center, Japan
| | - Dian-Jeng Li
- Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, I-Shou University School of Medicine for International Students
| | - Yu-Shian Cheng
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai’s Home, Taiwan
| | - Pin-Yang Yeh
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan; Clinical Psychology Center, Asia University Hospital, Taichung, Taiwan
| | - Yow-Ling Shiue
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
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22
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Baakman AC, Gavan C, van Doeselaar L, de Kam M, Broekhuizen K, Bajenaru O, Camps L, Swart EL, Kalisvaart K, Schoonenboom N, Lemstra E, Scheltens P, Cohen A, van Gerven J, Groeneveld GJ. Acute response to cholinergic challenge predicts long-term response to galantamine treatment in patients with Alzheimer's Disease. Br J Clin Pharmacol 2021; 88:2814-2829. [PMID: 34964149 PMCID: PMC9306507 DOI: 10.1111/bcp.15206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 11/30/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Cholinesterase inhibitors (CEIs) have been shown to improve cognitive functioning in Alzheimer's Disease (AD) patients, but are associated with multiple side effects and only 20-40% of the patients clinically improve. In this study, we aimed to investigate the acute pharmacodynamic (PD) effects of a single dose administration of galantamine on CNS functioning in mild to moderate AD patients and its potential to predict long-term treatment response. METHODS This study consisted of a challenge and treatment phase. In the challenge phase, a single dose of 16 mg galantamine was administered to 50 mild to moderate AD patients in a double-blind, placebo-controlled cross-over fashion. Acute PD effects were monitored up to 5 hours after administration with use of the NeuroCart CNS test battery and safety and pharmacokinetics were assessed. In the treatment phase, patients were treated with open-label galantamine according to regular clinical care. After 6 months of galantamine treatment, patients were categorized as either responder or as non-responder based on their MMSE, NPI and DAD scores. An analysis of covariance was performed to study the difference in acute PD effects during the challenge phase between responders and non-responders. RESULTS A single dose of galantamine significantly reduced saccadic reaction time (-0.0099; 95%CI=-0.0195,-0.0003; p=.0430), absolute frontal EEG parameters in alpha (-14.9; 95%CI=-21.0,-8.3; p=.0002), beta (-12.6; 95%CI=-19.4,-5.3; p=.0019) and theta (-17.9; 95%CI=-25.0,-10.0; p=.0001) frequencies. Relative frontal (-1.669; 95%CI=-2.999,-0.339; p=.0156) and occipital (-1.856; 95%CI=-3.339,-0.372; p=.0166) EEG power in theta frequency and relative occipital EEG power in the gamma frequency (1.316; 95%CI=0.158,2.475; p=.0273) also increased significantly compared to placebo. Acute decreases of absolute frontal alpha (-20.4; 95%CI=-31.6,-7.47; p=.0046), beta (-15.7; 95% CI=-28.3,-0.93; p=.0390) and theta (-25.9; 95%CI=-38.4,-10.9; p=.0024) EEG parameters and of relative frontal theta power (-3.27%; 95%CI=-5.96,-0.58; p=.0187) on EEG significantly distinguished responders (n=11) from non-responders (n=32) after 6 months. CONCLUSIONS This study demonstrates that acute PD effects after single dose of galantamine are correlated with long-term treatment effects and that patients who demonstrate a reduction in EEG power in the alpha and theta frequency after a single administration of galantamine 16 mg will most likely respond to treatment.
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Affiliation(s)
| | - Carmen Gavan
- Clinicii de neurologie a Spitalului Universitar de Urgenta, Bucharest, Romania
| | | | - Marieke de Kam
- Centre for Human Drug Research, CL, Leiden, The Netherlands
| | | | - Ovidiu Bajenaru
- Clinicii de neurologie a Spitalului Universitar de Urgenta, Bucharest, Romania
| | - Laura Camps
- Centre for Human Drug Research, CL, Leiden, The Netherlands
| | - Eleonora L Swart
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, HV, Amsterdam, The Netherlands
| | - Kees Kalisvaart
- Department of Neurology, Spaarne Gasthuis, Haarlem, The Netherlands
| | | | - Evelien Lemstra
- Alzheimer Center Amsterdam, Amsterdam UMC, HZ, Amsterdam, The Netherlands
| | - Philip Scheltens
- Alzheimer Center Amsterdam, Amsterdam UMC, HZ, Amsterdam, The Netherlands
| | - Adam Cohen
- Centre for Human Drug Research, CL, Leiden, The Netherlands
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23
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Ruangritchankul S, Chantharit P, Srisuma S, Gray LC. Adverse Drug Reactions of Acetylcholinesterase Inhibitors in Older People Living with Dementia: A Comprehensive Literature Review. Ther Clin Risk Manag 2021; 17:927-949. [PMID: 34511919 PMCID: PMC8427072 DOI: 10.2147/tcrm.s323387] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
The rising of global geriatric population has contributed to increased prevalence of dementia. Dementia is a neurodegenerative disease, which is characterized by progressive deterioration of cognitive functions, such as judgment, language, memory, attention and visuospatial ability. Dementia not only has profoundly devastating physical and psychological health outcomes, but it also poses a considerable healthcare expenditure and burdens. Acetylcholinesterase inhibitors (AChEIs), or so-called anti-dementia medications, have been developed to delay the progression of neurocognitive disorders and to decrease healthcare needs. AChEIs have been widely prescribed in clinical practice for the treatment of Alzheimer's disease, which account for 70% of dementia. The rising use of AChEIs results in increased adverse drug reactions (ADRs) such as cardiovascular and gastrointestinal adverse effects, resulting from overstimulation of peripheral cholinergic activity and muscarinic receptor activation. Changes in pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PGx), and occurrence of drug interactions are said to be major risk factors of ADRs of AChEIs in this population. To date, comprehensive reviews in ADRs of AChEIs have so far been scarcely studied. Therefore, we aimed to recapitulate and update the diverse aspects of AChEIs, including the mechanisms of action, characteristics and risk factors of ADRs, and preventive strategies of their ADRs. The collation of this knowledge is essential to facilitate efforts to reduce ADRs of AChEIs.
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Affiliation(s)
- Sirasa Ruangritchankul
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prawat Chantharit
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sahaphume Srisuma
- Ramathibodi Poison Center and Division of Clinical Pharmacology and Toxicology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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24
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Recent Progress on Biological Activity of Amaryllidaceae and Further Isoquinoline Alkaloids in Connection with Alzheimer's Disease. Molecules 2021; 26:molecules26175240. [PMID: 34500673 PMCID: PMC8434202 DOI: 10.3390/molecules26175240] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/22/2021] [Accepted: 08/27/2021] [Indexed: 11/16/2022] Open
Abstract
Alzheimer’s disease (AD) is a progressive age-related neurodegenerative disease recognized as the most common form of dementia among elderly people. Due to the fact that the exact pathogenesis of AD still remains to be fully elucidated, the treatment is only symptomatic and available drugs are not able to modify AD progression. Considering the increase in life expectancy worldwide, AD rates are predicted to increase enormously, and thus the search for new AD drugs is urgently needed. Due to their complex nitrogen-containing structures, alkaloids are considered to be promising candidates for use in the treatment of AD. Since the introduction of galanthamine as an antidementia drug in 2001, Amaryllidaceae alkaloids (AAs) and further isoquinoline alkaloids (IAs) have been one of the most studied groups of alkaloids. In the last few years, several compounds of new structure types have been isolated and evaluated for their biological activity connected with AD. The present review aims to comprehensively summarize recent progress on AAs and IAs since 2010 up to June 2021 as potential drugs for the treatment of AD.
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25
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Halder N, Lal G. Cholinergic System and Its Therapeutic Importance in Inflammation and Autoimmunity. Front Immunol 2021; 12:660342. [PMID: 33936095 PMCID: PMC8082108 DOI: 10.3389/fimmu.2021.660342] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
Neurological and immunological signals constitute an extensive regulatory network in our body that maintains physiology and homeostasis. The cholinergic system plays a significant role in neuroimmune communication, transmitting information regarding the peripheral immune status to the central nervous system (CNS) and vice versa. The cholinergic system includes the neurotransmitter\ molecule, acetylcholine (ACh), cholinergic receptors (AChRs), choline acetyltransferase (ChAT) enzyme, and acetylcholinesterase (AChE) enzyme. These molecules are involved in regulating immune response and playing a crucial role in maintaining homeostasis. Most innate and adaptive immune cells respond to neuronal inputs by releasing or expressing these molecules on their surfaces. Dysregulation of this neuroimmune communication may lead to several inflammatory and autoimmune diseases. Several agonists, antagonists, and inhibitors have been developed to target the cholinergic system to control inflammation in different tissues. This review discusses how various molecules of the neuronal and non-neuronal cholinergic system (NNCS) interact with the immune cells. What are the agonists and antagonists that alter the cholinergic system, and how are these molecules modulate inflammation and immunity. Understanding the various functions of pharmacological molecules could help in designing better strategies to control inflammation and autoimmunity.
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Affiliation(s)
- Namrita Halder
- Laboratory of Autoimmunity and Tolerance, National Centre for Cell Science, Ganeshkhind, Pune, India
| | - Girdhari Lal
- Laboratory of Autoimmunity and Tolerance, National Centre for Cell Science, Ganeshkhind, Pune, India
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26
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Chen Q, Wu S, Li X, Sun Y, Chen W, Lu J, Zhang W, Liu J, Qing Z, Nedelska Z, Hort J, Zhang X, Zhang B. Basal Forebrain Atrophy Is Associated With Allocentric Navigation Deficits in Subjective Cognitive Decline. Front Aging Neurosci 2021; 13:596025. [PMID: 33658916 PMCID: PMC7917187 DOI: 10.3389/fnagi.2021.596025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/27/2021] [Indexed: 01/21/2023] Open
Abstract
Individuals with subjective cognitive decline (SCD) are at higher risk of incipient Alzheimer's disease (AD). Spatial navigation (SN) impairments in AD dementia and mild cognitive impairment patients have been well-documented; however, studies investigating SN deficits in SCD subjects are still lacking. This study aimed to explore whether basal forebrain (BF) and entorhinal cortex (EC) atrophy contribute to spatial disorientation in the SCD stage. In total, 31 SCD subjects and 24 normal controls were enrolled and administered cognitive scales, a 2-dimensional computerized SN test, and structural magnetic resonance imaging (MRI) scanning. We computed the differences in navigation distance errors and volumes of BF subfields, EC, and hippocampus between the SCD and control groups. The correlations between MRI volumetry and navigation distance errors were also calculated. Compared with the controls, the SCD subjects performed worse in both egocentric and allocentric navigation. The SCD group showed volume reductions in the whole BF (p < 0.05, uncorrected) and the Ch4p subfield (p < 0.05, Bonferroni corrected), but comparable EC and hippocampal volumes with the controls. In the SCD cohort, the allocentric errors were negatively correlated with total BF (r = −0.625, p < 0.001), Ch4p (r = −0.625, p < 0.001), total EC (r = −0.423, p = 0.031), and left EC volumes (r = −0.442, p = 0.024), adjusting for age, gender, years of education, total intracranial volume, and hippocampal volume. This study demonstrates that SN deficits and BF atrophy may be promising indicators for the early detection of incipient AD patients. The reduced BF volume, especially in the Ch4p subfield, may serve as a structural basis for allocentric disorientation in SCD subjects independent of hippocampal atrophy. Our findings may have further implications for the preclinical diagnosis and intervention for potential AD patients.
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Affiliation(s)
- Qian Chen
- Department of Radiology, Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Sichu Wu
- Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xin Li
- Department of Radiology, Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Yi Sun
- Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wenqian Chen
- Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jiaming Lu
- Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wen Zhang
- Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jiani Liu
- Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhao Qing
- Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Institute of Brain Science, Nanjing University, Nanjing, China
| | - Zuzana Nedelska
- Memory Clinic, Department of Neurology, 2nd Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Jakub Hort
- Memory Clinic, Department of Neurology, 2nd Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Xin Zhang
- Department of Radiology, Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Bing Zhang
- Department of Radiology, Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Institute of Brain Science, Nanjing University, Nanjing, China
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27
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Se Thoe E, Fauzi A, Tang YQ, Chamyuang S, Chia AYY. A review on advances of treatment modalities for Alzheimer's disease. Life Sci 2021; 276:119129. [PMID: 33515559 DOI: 10.1016/j.lfs.2021.119129] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/10/2021] [Accepted: 01/19/2021] [Indexed: 12/15/2022]
Abstract
Alzheimer's disease (AD) is a multifactorial neurodegenerative disease which is mainly characterized by progressive impairment in cognition, emotion, language and memory in older population. Considering the impact of AD, formulations of pharmaceutical drugs and cholinesterase inhibitors have been widely propagated, receiving endorsement by FDA as a form of AD treatment. However, these medications were gradually discovered to be ineffective in removing the root of AD pathogenesis but merely targeting the symptoms so as to improve a patient's cognitive outcome. Hence, a search for better disease-modifying alternatives is put into motion. Having a clear understanding of the neuroprotective mechanisms and diverse properties undertaken by specific genes, antibodies and nanoparticles is central towards designing novel therapeutic agents. In this review, we provide a brief introduction on the background of Alzheimer's disease, the biology of blood-brain barrier, along with the potentials and drawbacks associated with current therapeutic treatment avenues pertaining to gene therapy, immunotherapy and nanotherapy for better diagnosis and management of Alzheimer's disease.
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Affiliation(s)
- Ewen Se Thoe
- School of Biosciences, Faculty of Health & Medical Sciences, Taylor's University, 47500 Selangor, Malaysia
| | - Ayesha Fauzi
- School of Biosciences, Faculty of Health & Medical Sciences, Taylor's University, 47500 Selangor, Malaysia
| | - Yin Quan Tang
- School of Biosciences, Faculty of Health & Medical Sciences, Taylor's University, 47500 Selangor, Malaysia
| | - Sunita Chamyuang
- School of Science, Mae Fah Luang University, Chaing Rai 57100, Thailand; Microbial Products and Innovation Research Group, Mae Fah Luang University, Chaing Rai 57100, Thailand
| | - Adeline Yoke Yin Chia
- School of Biosciences, Faculty of Health & Medical Sciences, Taylor's University, 47500 Selangor, Malaysia.
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28
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Watt JA, Campitelli MA, Maxwell CJ, Guan J, Maclagan LC, Gomes T, Bokhari M, Straus SE, Bronskill SE. Fall-Related Hospitalizations in Nursing Home Residents Co-Prescribed a Cholinesterase Inhibitor and Beta-Blocker. J Am Geriatr Soc 2021; 68:2516-2524. [PMID: 33460072 DOI: 10.1111/jgs.16710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND/OBJECTIVES To examine the association between hospitalization for a fall-related injury and the co-prescription of a cholinesterase inhibitor (ChEI) among persons with dementia receiving a beta-blocker, and whether this potential drug-drug interaction is modified by frailty. DESIGN Nested case-control study using population-based administrative databases. SETTING All nursing homes in Ontario, Canada. PARTICIPANTS Persons with dementia aged 66 and older who received at least one beta-blocker between April 2013 and March 2018 following nursing home admission (n = 19,060). MEASUREMENTS Cases were persons with dementia with a hospitalization (emergency department visit or acute care admission) for a fall-related injury with concurrent beta-blocker use. Each case (n = 3,038) was matched 1:1 to a control by age (±1 year), sex, cohort entry year, frailty, and history of fall-related injuries. The association between fall-related injury and exposure to a ChEI in the 90 days prior was examined using multivariable conditional logistic regression. Secondary exposures included ChEI type, daily dose, incident versus prevalent use, and use in the prior 30 days. Subgroup analyses considered frailty, age group, sex, and history of hospitalization for fall-related injuries. RESULTS Exposure to a ChEI in the prior 90 days occurred among 947 (31.2%) cases and 940 (30.9%) controls. In multivariable models, no association was found between hospitalization for a fall-related injury and prior exposure to a ChEI in persons with dementia dispensed beta-blockers (adjusted odds ratio = .96, 95% confidence interval = .85-1.08). Findings were consistent across secondary exposures and subgroup analyses. CONCLUSION Among nursing home residents with dementia receiving beta-blockers, co-prescription of a ChEI was not associated with an increased risk of hospitalization for a fall-related injury. However, we did not assess for its association with falls not leading to hospitalization. This finding could inform clinical guidelines and shared decision making between persons with dementia, caregivers, and clinicians concerning ChEI initiation and/or discontinuation.
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Affiliation(s)
- Jennifer A Watt
- St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Colleen J Maxwell
- ICES, Toronto, Ontario, Canada.,School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada.,School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | | | | | - Tara Gomes
- St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Mahmoud Bokhari
- Toronto General Hospital, Toronto, Ontario, Canada.,Mount Sinai Medical Center, New York, New York City, USA
| | - Sharon E Straus
- St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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29
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Marucci G, Buccioni M, Ben DD, Lambertucci C, Volpini R, Amenta F. Efficacy of acetylcholinesterase inhibitors in Alzheimer's disease. Neuropharmacology 2020; 190:108352. [PMID: 33035532 DOI: 10.1016/j.neuropharm.2020.108352] [Citation(s) in RCA: 376] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/21/2020] [Accepted: 10/05/2020] [Indexed: 11/26/2022]
Abstract
Alzheimer's disease (AD), the most common cause of adult-onset dementia is characterized by a progressive decline of cognitive functions accompanied by behavioral manifestations. The main class of drugs currently used for the treatment of AD are acetylcholinesterase/cholinesterase inhibitors (ChE-Is). The first ChE-I licensed for symptomatic treatment of AD was tacrine. The ChE-Is currently available in the market are donepezil, rivastigmine and galantamine as tacrine is no longer in use, due to its hepatotoxicity. According to mechanism of action the ChE-Is are classified as short-acting or reversible agents such as tacrine, donepezil, and galantamine, as intermediate-acting or pseudo-irreversible agent such as rivastigmine. Overall, the efficacy of the three ChE-Is available in the market is similar and the benefit of administration of these compounds is mild and may not be clinically significant. Due to gastrointestinal side effects of these drugs, medicinal chemistry and pharmaceutical delivery studies have investigated solutions to improve the pharmacological activity of these compounds. In spite of the limited activity of ChE-Is, waiting for more effective approaches, these drugs still represent a pharmacotherapeutic resource for the treatment of AD. Other approaches in which ChE-Is were investigated is in their use in combination with other classes of drugs such as cholinergic precursors, N-methyl-d-aspartate (NMDA) receptor antagonists and antioxidant agents. After many years from the introduction in therapy of ChE-Is, the combination with other classes of drugs may represent the chance for a renewed interest of ChE-Is in the treatment of adult-onset dementia disorders.
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Affiliation(s)
- Gabriella Marucci
- School of Medicinal Sciences and Health Products, Medicinal Chemistry Unit, University of Camerino, via S. Agostino 1, 62032, Camerino, Italy
| | - Michela Buccioni
- School of Medicinal Sciences and Health Products, Medicinal Chemistry Unit, University of Camerino, via S. Agostino 1, 62032, Camerino, Italy
| | - Diego Dal Ben
- School of Medicinal Sciences and Health Products, Medicinal Chemistry Unit, University of Camerino, via S. Agostino 1, 62032, Camerino, Italy
| | - Catia Lambertucci
- School of Medicinal Sciences and Health Products, Medicinal Chemistry Unit, University of Camerino, via S. Agostino 1, 62032, Camerino, Italy
| | - Rosaria Volpini
- School of Medicinal Sciences and Health Products, Medicinal Chemistry Unit, University of Camerino, via S. Agostino 1, 62032, Camerino, Italy
| | - Francesco Amenta
- School of Medicinal Sciences and Health Products, Telemedicine and Telepharmacy Center University of Camerino via Madonna delle Carceri 9, 62032, Camerino, Italy.
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30
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New coumarin-benzotriazole based hybrid molecules as inhibitors of acetylcholinesterase and amyloid aggregation. Bioorg Med Chem Lett 2020; 30:127477. [DOI: 10.1016/j.bmcl.2020.127477] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 11/21/2022]
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31
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Drugs Modulating CD4+ T Cells Blood-Brain Barrier Interaction in Alzheimer's Disease. Pharmaceutics 2020; 12:pharmaceutics12090880. [PMID: 32948022 PMCID: PMC7558445 DOI: 10.3390/pharmaceutics12090880] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/07/2020] [Accepted: 09/14/2020] [Indexed: 12/21/2022] Open
Abstract
The effect of Alzheimer’s disease (AD) medications on CD4+ T cells homing has not been thoroughly investigated. CD4+ T cells could both exacerbate and reduce AD symptoms based on their infiltrating subpopulations. Proinflammatory subpopulations such as Th1 and Th17 constitute a major source of proinflammatory cytokines that reduce endothelial integrity and stimulate astrocytes, resulting in the production of amyloid β. Anti-inflammatory subpopulations such as Th2 and Tregs reduce inflammation and regulate the function of Th1 and Th17. Recently, pathogenic Th17 has been shown to have a superior infiltrating capacity compared to other major CD4+ T cell subpopulations. Alzheimer’s drugs such as donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), and memantine (Namenda) are known to play an important part in regulating the mechanisms of the neurotransmitters. However, little is known about the effect of these drugs on CD4+ T cell subpopulations’ infiltration of the brain during AD. In this review, we focus on understanding the influence of AD drugs on CD4+ T cell subpopulation interactions with the BBB in AD. While current AD therapies improve endothelial integrity and reduce astrocytes activations, they vary according to their influence on various CD4+ T cell subpopulations. Donepezil reduces the numbers of Th1 but not Th2, Rivastigmine inhibits Th1 and Th17 but not Th2, and memantine reduces Th1 but not Treg. However, none of the current AD drugs is specifically designed to target the dysregulated balance in the Th17/Treg axis. Future drug design approaches should specifically consider inhibiting CD4+ Th17 to improve AD prognosis.
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32
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Gowayed MA, Mahmoud SA, Michel TN, Kamel MA, El-Tahan RA. Galantamine in rheumatoid arthritis: A cross talk of parasympathetic and sympathetic system regulates synovium-derived microRNAs and related pathogenic pathways. Eur J Pharmacol 2020; 883:173315. [DOI: 10.1016/j.ejphar.2020.173315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/18/2023]
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Le-Nhat-Thuy G, Nguyen Thi N, Pham-The H, Dang Thi TA, Nguyen Thi H, Nguyen Thi TH, Nguyen Hoang S, Nguyen TV. Synthesis and biological evaluation of novel quinazoline-triazole hybrid compounds with potential use in Alzheimer’s disease. Bioorg Med Chem Lett 2020; 30:127404. [DOI: 10.1016/j.bmcl.2020.127404] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 12/19/2022]
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Cacabelos R. Pharmacogenetic considerations when prescribing cholinesterase inhibitors for the treatment of Alzheimer's disease. Expert Opin Drug Metab Toxicol 2020; 16:673-701. [PMID: 32520597 DOI: 10.1080/17425255.2020.1779700] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Cholinergic dysfunction, demonstrated in the late 1970s and early 1980s, led to the introduction of acetylcholinesterase inhibitors (AChEIs) in 1993 (Tacrine) to enhance cholinergic neurotransmission as the first line of treatment against Alzheimer's disease (AD). The new generation of AChEIs, represented by Donepezil (1996), Galantamine (2001) and Rivastigmine (2002), is the only treatment for AD to date, together with Memantine (2003). AChEIs are not devoid of side-effects and their cost-effectiveness is limited. An option to optimize the correct use of AChEIs is the implementation of pharmacogenetics (PGx) in the clinical practice. AREAS COVERED (i) The cholinergic system in AD, (ii) principles of AD PGx, (iii) PGx of Donepezil, Galantamine, Rivastigmine, Huperzine and other treatments, and (iv) practical recommendations. EXPERT OPINION The most relevant genes influencing AChEI efficacy and safety are APOE and CYPs. APOE-4 carriers are the worst responders to AChEIs. With the exception of Rivastigmine (UGT2B7, BCHE-K), the other AChEIs are primarily metabolized via CYP2D6, CYP3A4, and UGT enzymes, with involvement of ABC transporters and cholinergic genes (CHAT, ACHE, BCHE, SLC5A7, SLC18A3, CHRNA7) in most ethnic groups. Defective variants may affect the clinical response to AChEIs. PGx geno-phenotyping is highly recommended prior to treatment.
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Affiliation(s)
- Ramón Cacabelos
- Department of Genomic Medicine, EuroEspes Biomedical Research Center, International Center of Neuroscience and Genomic Medicine , Bergondo, Corunna, Spain
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Lu J, Wang X, Wan L, Fu J, Huo Y, Zhao Y, Guo C. Gene Polymorphisms Affecting the Pharmacokinetics and Pharmacodynamics of Donepezil Efficacy. Front Pharmacol 2020; 11:934. [PMID: 32636753 PMCID: PMC7317019 DOI: 10.3389/fphar.2020.00934] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 06/08/2020] [Indexed: 12/15/2022] Open
Abstract
Donepezil (DNP) is the first-line drug used for Alzheimer's disease (AD). However, the therapeutic response rate of patients to DNP varies from 20 to 60%. The main reason for the large differences in the clinical efficacy of DNP therapy is genetic factors, some of which affect pharmacokinetics (PK), while others affect pharmacodynamics (PD). Thus, much emphasis has been placed on the investigation of an association between PK- and PD-related gene polymorphisms and therapeutic response to DNP, but a consistent view does not yet exist. In this review, we summarize recent findings regarding genetic factors influencing the clinical efficacy of DNP, including substantial differences in individual responses as a consequence of polymorphisms in Cytochrome P450 (CYP) 2D6, CY3A4, CY3A5, APOE, ABCA1, ABCB1, ESR1, BCHE, PON-1, CHRNA7, and CHAT. We also discuss possible strategies for the evaluation of the clinical efficacy of DNP, with a specific focus on possible biomarkers of PK/PD parameters, and provide perspectives and limitations within the field, which will also be beneficial for understanding the multiple mechanisms of DNP therapy in AD.
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Affiliation(s)
- Jin Lu
- Department of Pharmacy, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiuzhe Wang
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lili Wan
- Department of Pharmacy, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jianliang Fu
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yan Huo
- Department of Pharmacy, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cheng Guo
- Department of Pharmacy, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
- School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Kabir MT, Uddin MS, Begum MM, Thangapandiyan S, Rahman MS, Aleya L, Mathew B, Ahmed M, Barreto GE, Ashraf GM. Cholinesterase Inhibitors for Alzheimer's Disease: Multitargeting Strategy Based on Anti-Alzheimer's Drugs Repositioning. Curr Pharm Des 2020; 25:3519-3535. [PMID: 31593530 DOI: 10.2174/1381612825666191008103141] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/01/2019] [Indexed: 02/06/2023]
Abstract
In the brain, acetylcholine (ACh) is regarded as one of the major neurotransmitters. During the advancement of Alzheimer's disease (AD) cholinergic deficits occur and this can lead to extensive cognitive dysfunction and decline. Acetylcholinesterase (AChE) remains a highly feasible target for the symptomatic improvement of AD. Acetylcholinesterase (AChE) remains a highly viable target for the symptomatic improvement in AD because cholinergic deficit is a consistent and early finding in AD. The treatment approach of inhibiting peripheral AChE for myasthenia gravis had effectively proven that AChE inhibition was a reachable therapeutic target. Subsequently tacrine, donepezil, rivastigmine, and galantamine were developed and approved for the symptomatic treatment of AD. Since then, multiple cholinesterase inhibitors (ChEIs) have been continued to be developed. These include newer ChEIs, naturally derived ChEIs, hybrids, and synthetic analogues. In this paper, we summarize the different types of ChEIs which are under development and their respective mechanisms of actions.
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Affiliation(s)
| | - Md Sahab Uddin
- Department of Pharmacy, Southeast University, Dhaka, Bangladesh.,Pharmakon Neuroscience Research Network, Dhaka, Bangladesh
| | | | | | - Md Sohanur Rahman
- Graduate School of Innovative Life Science, University of Toyama, Toyama, Japan
| | - Lotfi Aleya
- Chrono-Environnement Laboratory, CNRS 6249, Bourgogne Franche-Comté University, Besançon, France
| | - Bijo Mathew
- Division of Drug Design and Medicinal Chemistry Research Lab, Department of Pharmaceutical Chemistry, Ahalia School of Pharmacy, Palakkad, India
| | - Muniruddin Ahmed
- Department of Pharmacy, Daffodil International University, Dhaka, Bangladesh
| | - George E Barreto
- Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Santiago, Chile
| | - Ghulam Md Ashraf
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
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Di Lorenzo F, Motta C, Casula EP, Bonnì S, Assogna M, Caltagirone C, Martorana A, Koch G. LTP-like cortical plasticity predicts conversion to dementia in patients with memory impairment. Brain Stimul 2020; 13:1175-1182. [PMID: 32485235 DOI: 10.1016/j.brs.2020.05.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND New diagnostic criteria consider Alzheimer's disease (AD) as a clinico-biological entity identifiable in vivo on the presence of specific patterns of CSF biomarkers. OBJECTIVE Here we used transcranial magnetic stimulation to investigate the mechanisms of cortical plasticity and sensory-motor integration in patients with hippocampal-type memory impairment admitted for the first time in the memory clinic stratified according to CSF biomarkers profile. METHODS Seventy-three patients were recruited and divided in three groups according to the new diagnostic criteria: 1) Mild Cognitive Impaired (MCI) patients (n = 21); Prodromal AD (PROAD) patients (n = 24); AD with manifest dementia (ADD) patients (n = 28). At time of recruitment all patients underwent CSF sampling for diagnostic purposes. Repetitive and paired-pulse transcranial magnetic stimulation protocols were performed to investigate LTP-like and LTD-like cortical plasticity, short intracortical inhibition (SICI) and short afferent inhibition (SAI). Patients were the followed up during three years to monitor the clinical progression or the conversion to dementia. RESULTS MCI patients showed a moderate but significant impairment of LTP-like cortical plasticity, while ADD and PROAD groups showed a more severe loss of LTP-like cortical plasticity. No differences were observed for LTD-like cortical plasticity, SICI and SAI protocols. Kaplan-Meyer analyses showed that PROAD and MCI patients converting to dementia had weaker LTP-like plasticity at time of first evaluation. CONCLUSION LTP-like cortical plasticity could be a novel biomarker to predict the clinical progression to dementia in patients with memory impairment at prodromal stages of AD identifiable with the new diagnostic criteria based on CSF biomarkers.
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Affiliation(s)
- Francesco Di Lorenzo
- Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - Caterina Motta
- Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy; Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Elias Paolo Casula
- Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - Sonia Bonnì
- Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - Martina Assogna
- Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - Carlo Caltagirone
- Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - Alessandro Martorana
- Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy; Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Giacomo Koch
- Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy; Section of Human Physiology, ECampus University, Novedrate, Italy.
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Zhang T, Liu N, Cao H, Wei W, Ma L, Li H. Different Doses of Pharmacological Treatments for Mild to Moderate Alzheimer's Disease: A Bayesian Network Meta-Analysis. Front Pharmacol 2020; 11:778. [PMID: 32528296 PMCID: PMC7264393 DOI: 10.3389/fphar.2020.00778] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/11/2020] [Indexed: 12/21/2022] Open
Abstract
Background Pharmacological treatments play a significant role in treating mild to moderate Alzheimer's disease (AD), but the optimal doses of various drugs used for these treatments are unknown. Our study compared the efficacy, acceptability, and safety of different doses of pharmacological treatments for mild to moderate AD. Methods Randomized controlled trials (RCTs) were identified by searching the PubMed, EMBASE, and Cochrane Library databases (all RCTs published from the date of inception of the databases until September 19, 2019). Trials comparing the efficacy, acceptability, and safety of pharmacological interventions involving donepezil, galantamine, rivastigmine, memantine, huperzine A, and Ginkgo biloba extract EGb761, alone or in combination, were identified. The primary outcomes were efficacy, acceptability, and safety. Results Our meta-analysis included 37 studies involving 14,705 participants. In terms of improving cognitive function, galantamine 32 mg, galantamine 24 mg, donepezil 5 mg, and donepezil 10 mg were more effective than other interventions, with the surface under the cumulative ranking curve (SUCRA) values of 93.2, 75.5, 73.3, and 65.6%, respectively. According to the SUCRA values, EGb761 240 mg was considered to be the optimal intervention in terms of both acceptability and safety. With regard to clinical global impression, rivastigmine 12 mg had the highest probability of being ranked first (83.7%). The rivastigmine 15 cm2 patch (SUCRA = 93.7%) may be the best choice for daily living. However, there were no interventions that could significantly improve neuropsychiatric symptoms, compared with the placebo. Conclusions Different doses of the tested pharmacological interventions yielded benefits with regard to cognition, acceptability, safety, function, and clinical global impressions, but not effective behaviors.
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Affiliation(s)
- Tingting Zhang
- College of First Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Nanyang Liu
- Department of Geratology, Xiyuan Hospital, China Academy of Chinese Medical Science, Beijing, China
| | - Hongfu Cao
- Institute of Basic Theory for Chinese Medicine, China Academy of Chinese Medical Science, Beijing, China
| | - Wei Wei
- College of First Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Lina Ma
- Department of Geratology, Xiyuan Hospital, China Academy of Chinese Medical Science, Beijing, China
| | - Hao Li
- Department of Geratology, Xiyuan Hospital, China Academy of Chinese Medical Science, Beijing, China
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Functional characterization of multifunctional ligands targeting acetylcholinesterase and alpha 7 nicotinic acetylcholine receptor. Biochem Pharmacol 2020; 177:114010. [PMID: 32360492 DOI: 10.1016/j.bcp.2020.114010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/28/2020] [Indexed: 11/20/2022]
Abstract
Alzheimer's disease (AD) is a neurodegenerative disorder associated with cholinergic dysfunction, provoking memory loss and cognitive dysfunction in elderly patients. The cholinergic hypothesis provided over the years with molecular targets for developing palliative treatments for AD, acting on the cholinergic system, namely, acetylcholinesterase and α7 nicotinic acetylcholine receptor (α7 nAChR). In our synthetic work, we used "click-chemistry" to synthesize two Multi Target Directed Ligands (MTDLs) MB105 and MB118 carrying tacrine and quinuclidine scaffolds which are known for their anticholinesterase and α7 nAChR agonist activities, respectively. Both, MB105 and MB118, inhibit human acetylcholinesterase and human butyrylcholinesterase in the nanomolar range. Electrophysiological recordings on Xenopus laevis oocytes expressing human α7 nAChR showed that MB105 and MB118 acted as partial agonists of the referred nicotinic receptor, albeit, with different potencies despite their similar structure. The different substitution at C-3 on the 2,3-disubstituted quinuclidine scaffold may account for the significantly lower potency of MB118 compared to MB105. Electrophysiological recordings also showed that the tacrine precursor MB320 behaved as a competitive antagonist of human α7 nAChR, in the micromolar range, while the quinuclidine synthetic precursor MB099 acted as a partial agonist. Taken all together, MB105 behaved as a partial agonist of α7 nAChR at concentrations where it completely inhibited human acetylcholinesterase activity paving the way for the design of novel MTDLs for palliative treatment of AD.
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Patnode CD, Perdue LA, Rossom RC, Rushkin MC, Redmond N, Thomas RG, Lin JS. Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2020; 323:764-785. [PMID: 32096857 DOI: 10.1001/jama.2019.22258] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Early identification of cognitive impairment may improve patient and caregiver health outcomes. OBJECTIVE To systematically review the test accuracy of cognitive screening instruments and benefits and harms of interventions to treat cognitive impairment in older adults (≥65 years) to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials through January 2019, with literature surveillance through November 22, 2019. STUDY SELECTION Fair- to good-quality English-language studies of cognitive impairment screening instruments, and pharmacologic and nonpharmacologic treatments aimed at persons with mild cognitive impairment (MCI), mild to moderate dementia, or their caregivers. DATA EXTRACTION AND SYNTHESIS Independent critical appraisal and data abstraction; random-effects meta-analyses and qualitative synthesis. MAIN OUTCOMES AND MEASURES Sensitivity, specificity; patient, caregiver, and clinician decision-making; patient function, quality of life, and neuropsychiatric symptoms; caregiver burden and well-being. RESULTS The review included 287 studies with more than 280 000 older adults. One randomized clinical trial (RCT) (n = 4005) examined the direct effect of screening for cognitive impairment on patient outcomes, including potential harms, finding no significant differences in health-related quality of life at 12 months (effect size, 0.009 [95% CI, -0.063 to 0.080]). Fifty-nine studies (n = 38 531) addressed the accuracy of 49 screening instruments to detect cognitive impairment. The Mini-Mental State Examination was the most-studied instrument, with a pooled sensitivity of 0.89 (95% CI, 0.85 to 0.92) and specificity of 0.89 (95% CI, 0.85 to 0.93) to detect dementia using a cutoff of 23 or less or 24 or less (15 studies, n = 12 796). Two hundred twenty-four RCTs and 3 observational studies including more than 240 000 patients or caregivers addressed the treatment of MCI or mild to moderate dementia. None of the treatment trials were linked with a screening program; in all cases, participants were persons with known cognitive impairment. Medications approved to treat Alzheimer disease (donepezil, galantamine, rivastigmine, and memantine) improved scores on the ADAS-Cog 11 by 1 to 2.5 points over 3 months to 3 years. Psychoeducation interventions for caregivers resulted in a small benefit for caregiver burden (standardized mean difference, -0.24 [95% CI, -0.36 to -0.13) over 3 to 12 months. Intervention benefits were small and of uncertain clinical importance. CONCLUSIONS AND RELEVANCE Screening instruments can adequately detect cognitive impairment. There is no empirical evidence, however, that screening for cognitive impairment improves patient or caregiver outcomes or causes harm. It remains unclear whether interventions for patients or caregivers provide clinically important benefits for older adults with earlier detected cognitive impairment or their caregivers.
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Affiliation(s)
- Carrie D Patnode
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | | | - Megan C Rushkin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Nadia Redmond
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Jennifer S Lin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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Hameed S, Fuh JL, Senanarong V, Ebenezer EGM, Looi I, Dominguez JC, Park KW, Karanam AK, Simon O. Role of Fluid Biomarkers and PET Imaging in Early Diagnosis and its Clinical Implication in the Management of Alzheimer's Disease. J Alzheimers Dis Rep 2020; 4:21-37. [PMID: 32206755 PMCID: PMC7081089 DOI: 10.3233/adr-190143] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2020] [Indexed: 12/13/2022] Open
Abstract
Clinical diagnosis of Alzheimer's disease (AD) is based on symptoms; however, the challenge is to diagnose AD at the preclinical stage with the application of biomarkers and initiate early treatment (still not widely available). Currently, cerebrospinal fluid (CSF) amyloid-β 42 (Aβ42) and tau are used in the clinical diagnosis of AD; nevertheless, blood biomarkers (Aβ42 and tau) are less predictive. Amyloid-positron emission tomography (PET) imaging is an advancement in technology that uses approved radioactive diagnostic agents (florbetapir, flutemetamol, or florbetaben) to estimate Aβ neuritic plaque density in adults with cognitive impairment evaluated for AD and other causes of cognitive decline. There is no cure for AD to date-the disease progression cannot be stopped or reversed; approved pharmacological agents (donepezil, galantamine, and rivastigmine; memantine) provide symptomatic treatment. However, the disease-modifying therapies are promising; aducanumab and CAD106 are in phase III trials for the early stages of AD. In conclusion, core CSF biomarkers reflect pathophysiology of AD in the early and late stages; the application of approved radiotracers have potential in amyloid-PET brain imaging to detect early AD.
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Affiliation(s)
- Shahul Hameed
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore
- Duke NUS Medical School, Singapore
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Vorapun Senanarong
- Division of Neurology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Irene Looi
- Clinical Research Centre, Hospital Seberang Jaya, Penang, Malaysia
- Department of Medicine, Hospital Seberang Jaya, Penang, Malaysia
| | | | - Kyung Won Park
- Department of Neurology and Cognitive Disorders and Dementia Center, Institute of Convergence Bio-Health, Dong-A University College of Medicine, Busan, Republic of Korea
| | | | - Oliver Simon
- Novartis (Singapore) Pte. Ltd., Singapore, Singapore
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Methylphenidate and galantamine in patients with vascular cognitive impairment-the proof-of-principle study STREAM-VCI. ALZHEIMERS RESEARCH & THERAPY 2020; 12:10. [PMID: 31910895 PMCID: PMC6947990 DOI: 10.1186/s13195-019-0567-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 12/06/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND To date, no symptomatic treatment is available for patients with vascular cognitive impairment (VCI). In the proof-of-principle study Symptomatic Treatment of Vascular Cognitive Impairment (STREAM-VCI), we investigated whether a single dose of a monoaminergic drug (methylphenidate) improves executive functioning and whether a single dose of a cholinergic drug (galantamine) improves memory in VCI patients. METHODS STREAM-VCI is a single-center, double-blind, three-way crossover trial. We included 30 VCI patients (Mini-Mental State Examination (MMSE) ≥ 16 and Clinical Dementia Rating score 0.5-1.0) with cerebrovascular pathology on MRI. All patients received single doses of methylphenidate (10 mg), galantamine (16 mg), and placebo in random order on three separate study visits. We used the NeuroCart®, a computerized test battery, to assess drug-sensitive cognitive effects. Predefined main outcomes, measured directly after a single dose of a study drug, were (i) change in performance on the adaptive tracker for executive functioning and (ii) performance on the Visual Verbal Learning Test-15 (VVLT-15) for memory, compared to placebo. We performed mixed model analysis of variance. RESULTS The study population had a mean age of 67 ± 8 years and MMSE 26 ± 3, and 9 (30%) were female. Methylphenidate improved performance on the adaptive tracker more than placebo (mean difference 1.40%; 95% confidence interval [CI] 0.56-2.25; p = 0.002). In addition, methylphenidate led to better memory performance on the VVLT-15 compared to placebo (mean difference in recalled words 0.59; 95% CI 0.03-1.15; p = 0.04). Galantamine did not improve performance on the adaptive tracker and led to worse performance on delayed recall of the VVLT-15 (mean difference - 0.84; 95% CI - 1.65, - 0.03; p = 0.04). Methylphenidate was well tolerated while galantamine produced gastrointestinal side effects in a considerable number of patients. CONCLUSIONS In this proof-of-principle study, methylphenidate is well tolerated and improves executive functioning and immediate recall in patients with VCI. Galantamine did not improve memory or executive dysfunction. Results might be influenced by the considerable amount of side effects seen. TRIAL REGISTRATION http://www.clinicaltrials.gov. Registration number: NCT02098824. Registration date: March 28, 2014.
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Karami A, Eriksdotter M, Kadir A, Almkvist O, Nordberg A, Darreh-Shori T. CSF Cholinergic Index, a New Biomeasure of Treatment Effect in Patients With Alzheimer's Disease. Front Mol Neurosci 2019; 12:239. [PMID: 31680850 PMCID: PMC6798072 DOI: 10.3389/fnmol.2019.00239] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/19/2019] [Indexed: 02/04/2023] Open
Abstract
Alzheimer’s disease (AD) is a progressive disease with early degeneration of the central cholinergic neurons. Currently, three of four AD drugs act by inhibiting the acetylcholine (ACh) degrading enzyme, acetylcholinesterase (AChE). Efficacy of these drugs depends on available amount of ACh, which is biosynthesized by choline acetyltransferase (ChAT). We investigated whether treatment with a cholinesterase-inhibitor, galantamine, alters the relative levels of AChE to ChAT in cerebrospinal fluid (CSF) and whether levels of these CSF biomarkers correlate with in vivo AChE activity and nicotinic binding sites in the brain assessed by positron emission tomography (PET). Protein concentrations and activities of ChAT and AChE were measured in CSF of 18 patients with mild AD prior to and after 3 months of treatment with galantamine (n = 12) or placebo (n = 6), followed by nine additional months of galantamine treatment in all patients. A Cholinergic index was defined as the ratio of ChAT to AChE in CSF and was evaluated in relation to the in vivo AChE activity, the nicotinic binding sites and different measures of cognition. Besides an expected inhibition of AChE activity, galantamine treatment was accompanied by a mild increase in CSF ChAT activity. Thereby, the Cholinergic index was significantly increased in the Galantamine group (60% ± 14) after 3 months compared to baseline (p < 0.0023) or (p < 0.0004). This index remained high in the Galantamine group compared to baseline (54% ± 11) at 12 months follow-up, while it showed an increase in the Placebo group when they switched to active galantamine treatment (44% ± 14 vs. baseline, 61% ± 14 vs. 3 months, all p-values < 0.05). Furthermore, the in vivo brain AChE activity (assessed by PET) correlated with the CSF Cholinergic index at 12 months (r = 0.98, p < 0.001). The CSF Cholinergic index also correlated with ADAS-Cog and some other neuropsychological tests at 12 months. This is the first study assessing a CSF Cholinergic index in relation to treatment with a cholinesterase inhibitor. The treatment-specific increase in CSF ChAT activity suggests that cholinesterase-inhibitors may also increase the ACh-biosynthesis capacity in the patients. Additional studies are warranted to evaluate the utility of the CSF Cholinergic index as a biomeasure of therapeutic effect in AD.
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Affiliation(s)
- Azadeh Karami
- Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Solna, Sweden
| | - Maria Eriksdotter
- Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Solna, Sweden.,Karolinska University Hospital Huddinge, Theme Aging, Stockholm, Sweden
| | - Ahmadul Kadir
- Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Solna, Sweden.,Karolinska University Hospital Huddinge, Theme Aging, Stockholm, Sweden
| | - Ove Almkvist
- Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Solna, Sweden
| | - Agneta Nordberg
- Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Solna, Sweden.,Karolinska University Hospital Huddinge, Theme Aging, Stockholm, Sweden
| | - Taher Darreh-Shori
- Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Solna, Sweden
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Thancharoen O, Limwattananon C, Waleekhachonloet O, Rattanachotphanit T, Limwattananon P, Limpawattana P. Ginkgo biloba Extract (EGb761), Cholinesterase Inhibitors, and Memantine for the Treatment of Mild-to-Moderate Alzheimer's Disease: A Network Meta-Analysis. Drugs Aging 2019; 36:435-452. [PMID: 30937879 DOI: 10.1007/s40266-019-00648-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cholinesterase inhibitors (ChEIs) and memantine have been reported to provide modest benefits for cognition and aspects of functioning in Alzheimer's disease (AD). Ginkgo biloba extract (EGb761), a phytomedicine, is widely used and expected to be well-tolerated. A few trials have compared EGb761 with ChEIs, and the results were inconclusive. OBJECTIVE A network meta-analysis was conducted to evaluate the therapeutic benefits and tolerability of EGb761, three ChEIs (donepezil, galantamine, and rivastigmine), and memantine in mild-to-moderate AD patients. METHODS Electronic databases were searched through 30 June 2017. We included randomized double-blinded trials with a minimum treatment duration of 22 weeks for EGb761 240 mg/day and 12 weeks for ChEIs or memantine. The study patients included AD or probable AD patients without other types of dementia or neurological disorders. Cognition, function, and behavior symptoms were compared between treatments using the standardized mean difference (SMD). Clinical global impression, treatment discontinuation, and adverse events were compared between treatments using the relative risk (RR). Statistical pooling of the individual trial results was conducted using a frequentist approach. The probability of being the best for a treatment was estimated using surface under the cumulative ranking. RESULTS EGb761 and memantine showed no therapeutic benefits in all study outcomes. For cognition, all ChEIs were significantly better than placebo (SMD from - 0.52 to - 0.26), and galantamine was better than rivastigmine in the oral and patch forms, EGb761, and memantine (SMD [95% confidence interval (CI)]: - 0.22 [- 0.40 to - 0.05]; - 0.26 [- 0.45 to - 0.07]; - 0.34 [- 0.56 to - 0.12]; and - 0.42 [- 0.71 to - 0.13], respectively). Compared to placebo, galantamine, the rivastigmine patch, and oral rivastigmine provided modest functional benefits (SMD, from 0.21 to 0.24), and galantamine provided behavioral benefits (SMD [95% CI]: - 0.15 [- 0.26 to - 0.04]). All ChEIs provided a better improvement in clinical global impression than placebo (RR from 1.20 to 1.69). The global impression ratings were more improved with donepezil than with galantamine (RR [95% CI]: 1.40 [1.09-1.80]) or with EGb761 (RR [95% CI]: 1.40 [1.06-1.85]), with a 96% probability of donepezil being more effective than the other study agents. Rivastigmine in oral and patch forms, galantamine, and donepezil had a higher risk of being discontinued than placebo (RR [95% CI]: 2.14 [1.49-3.06]; 2.04 [1.30-3.20]; 1.79 [1.28-2.49]; 1.49 [1.03-2.17], respectively). Discontinuation of EGb761 was not statistically lower than that of the ChEIs, in which donepezil had the lowest probability (38%) of being discontinued. CONCLUSION EGb761 and memantine showed no treatment benefits compared to placebo and ChEIs. Galantamine provided the highest beneficial effect on cognition and behavioral symptoms. Donepezil provided a better clinical global impression and tolerability than the other ChEIs and EGb761, with a similar benefit for cognition as galantamine.
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Affiliation(s)
- Onnita Thancharoen
- Pharmacy and Health System Graduate Program, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Chulaporn Limwattananon
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, 123 Moo 16 Mittraphap Road, Muang District, Khon Kaen, 40002, Thailand.
| | - Onanong Waleekhachonloet
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mahasarakham University, Maha Sarakham, Thailand
| | | | | | - Panita Limpawattana
- Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Karakoyun Ç, Masi M, Cimmino A, Önür MA, Somer NU, Kornienko A, Evidente A. A Brief Up-to-Date Overview of Amaryllidaceae Alkaloids: Phytochemical Studies of Narcissus tazetta subsp. tazetta L., Collected in Turkey. Nat Prod Commun 2019. [DOI: 10.1177/1934578x19872906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A brief up-to-date overview on the isolation, and chemical and biological characterization of new and known alkaloids from different Amaryllidaceae species, including Brunsvigia, Crinum, Cyrtanthus, Narcissus, and Nerine genera, was reported. Furthermore, the isolation and chemical characterization of alkaloids extracted from bulbs of Narcissus tazetta subsp. tazetta L. collected from Muğla, Turkey were described.
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Affiliation(s)
- Çiğdem Karakoyun
- Department of Pharmacognosy, Faculty of Pharmacy, Ege University, İzmir, Turkey
| | - Marco Masi
- Department of Chemical Sciences, University of Naples Federico II, Complesso Universitario Monte San’Angelo, Italy
| | - Alessio Cimmino
- Department of Chemical Sciences, University of Naples Federico II, Complesso Universitario Monte San’Angelo, Italy
| | - Mustafa Ali Önür
- Department of Pharmacognosy, Faculty of Pharmacy, Ege University, İzmir, Turkey
| | - Nehir Unver Somer
- Department of Pharmacognosy, Faculty of Pharmacy, Ege University, İzmir, Turkey
| | - Alexander Kornienko
- Department of Chemistry and Biochemistry, Texas State University, San Marcos, TX, USA
| | - Antonio Evidente
- Department of Pharmacognosy, Faculty of Pharmacy, Ege University, İzmir, Turkey
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Hampel H, Mesulam MM, Cuello AC, Farlow MR, Giacobini E, Grossberg GT, Khachaturian AS, Vergallo A, Cavedo E, Snyder PJ, Khachaturian ZS. The cholinergic system in the pathophysiology and treatment of Alzheimer's disease. Brain 2019; 141:1917-1933. [PMID: 29850777 DOI: 10.1093/brain/awy132] [Citation(s) in RCA: 909] [Impact Index Per Article: 181.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/29/2018] [Indexed: 12/19/2022] Open
Abstract
Cholinergic synapses are ubiquitous in the human central nervous system. Their high density in the thalamus, striatum, limbic system, and neocortex suggest that cholinergic transmission is likely to be critically important for memory, learning, attention and other higher brain functions. Several lines of research suggest additional roles for cholinergic systems in overall brain homeostasis and plasticity. As such, the brain's cholinergic system occupies a central role in ongoing research related to normal cognition and age-related cognitive decline, including dementias such as Alzheimer's disease. The cholinergic hypothesis of Alzheimer's disease centres on the progressive loss of limbic and neocortical cholinergic innervation. Neurofibrillary degeneration in the basal forebrain is believed to be the primary cause for the dysfunction and death of forebrain cholinergic neurons, giving rise to a widespread presynaptic cholinergic denervation. Cholinesterase inhibitors increase the availability of acetylcholine at synapses in the brain and are one of the few drug therapies that have been proven clinically useful in the treatment of Alzheimer's disease dementia, thus validating the cholinergic system as an important therapeutic target in the disease. This review includes an overview of the role of the cholinergic system in cognition and an updated understanding of how cholinergic deficits in Alzheimer's disease interact with other aspects of disease pathophysiology, including plaques composed of amyloid-β proteins. This review also documents the benefits of cholinergic therapies at various stages of Alzheimer's disease and during long-term follow-up as visualized in novel imaging studies. The weight of the evidence supports the continued value of cholinergic drugs as a standard, cornerstone pharmacological approach in Alzheimer's disease, particularly as we look ahead to future combination therapies that address symptoms as well as disease progression.
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Affiliation(s)
- Harald Hampel
- AXA Research Fund and Sorbonne University Chair, Paris, France.,Sorbonne University, GRC n° 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Boulevard de l'hôpital, Paris, France.,Brain and Spine Institute (ICM), INSERM U 1127, CNRS UMR 7225, Boulevard de l'hôpital, Paris, France.,Institute of Memory and Alzheimer's Disease (IM2A), Department of Neurology, Pitié-Salpêtrière Hospital, AP-HP, Boulevard de l'hôpital, Paris, France
| | - M-Marsel Mesulam
- Cognitive Neurology and Alzheimer's Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A Claudio Cuello
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Canada.,Department of Anatomy and Cell Biology, McGill University, Montreal, Canada
| | - Martin R Farlow
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ezio Giacobini
- Department of Internal Medicine, Rehabilitation and Geriatrics, University of Geneva Hospitals, Geneva, Switzerland
| | - George T Grossberg
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Ara S Khachaturian
- The Campaign to Prevent Alzheimer's Disease by 2020 (PAD2020), Potomac, MD, USA
| | - Andrea Vergallo
- AXA Research Fund and Sorbonne University Chair, Paris, France.,Sorbonne University, GRC n° 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Boulevard de l'hôpital, Paris, France.,Brain and Spine Institute (ICM), INSERM U 1127, CNRS UMR 7225, Boulevard de l'hôpital, Paris, France.,Institute of Memory and Alzheimer's Disease (IM2A), Department of Neurology, Pitié-Salpêtrière Hospital, AP-HP, Boulevard de l'hôpital, Paris, France
| | - Enrica Cavedo
- AXA Research Fund and Sorbonne University Chair, Paris, France.,Sorbonne University, GRC n° 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Boulevard de l'hôpital, Paris, France.,Brain and Spine Institute (ICM), INSERM U 1127, CNRS UMR 7225, Boulevard de l'hôpital, Paris, France.,Institute of Memory and Alzheimer's Disease (IM2A), Department of Neurology, Pitié-Salpêtrière Hospital, AP-HP, Boulevard de l'hôpital, Paris, France
| | - Peter J Snyder
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI USA.,Ryan Institute for Neuroscience, University of Rhode Island, Kingston, RI, USA
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Abstract
There are 3 common physiological estrogens, of which estradiol (E2) is seen to decline rapidly over the menopausal transition. This decline in E2 has been associated with a number of changes in the brain, including cognitive changes, effects on sleep, and effects on mood. These effects have been demonstrated in both rodent and non-human preclinical models. Furthermore, E2 interactions have been indicated in a number of neuropsychiatric disorders, including Alzheimer's disease, schizophrenia, and depression. In normal brain aging, there are a number of systems that undergo changes and a number of these show interactions with E2, particularly the cholinergic system, the dopaminergic system, and mitochondrial function. E2 treatment has been shown to ameliorate some of the behavioral and morphological changes seen in preclinical models of menopause; however, in clinical populations, the effects of E2 treatment on cognitive changes after menopause are mixed. The future use of sex hormone treatment will likely focus on personalized or precision medicine for the prevention or treatment of cognitive disturbances during aging, with a better understanding of who may benefit from such treatment.
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Affiliation(s)
- Jason K Russell
- Department of Pharmacology, Vanderbilt University, Nashville, TN, 37232, USA
- Vanderbilt Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, TN, 37232, USA
| | - Carrie K Jones
- Department of Pharmacology, Vanderbilt University, Nashville, TN, 37232, USA
- Vanderbilt Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, TN, 37232, USA
| | - Paul A Newhouse
- Center for Cognitive Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, 37212, USA.
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee VA Health Systems, Nashville, TN, 37212, USA.
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Rao T, Tan Z, Peng J, Guo Y, Chen Y, Zhou H, Ouyang D. The pharmacogenetics of natural products: A pharmacokinetic and pharmacodynamic perspective. Pharmacol Res 2019; 146:104283. [PMID: 31129178 DOI: 10.1016/j.phrs.2019.104283] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 11/19/2022]
Abstract
Natural products have represented attractive alternatives for disease prevention and treatment over the course of human history and have contributed to the development of modern drugs. These natural products possess beneficial efficacies as well as adverse efffects, which vary largely among individuals because of genetic variations in their pharmacokinetics and pharmacodynamics. As with other synthetic chemical drugs, the dosing of natural products can be optimized to improve efficacy and reduce toxicity according to the pharmacogenetic properties. With the emergence and development of pharmacogenomics, it is possible to discover and identify the targets/mechanisms of pharmacological effects and therapeutic responses of natural products effectively and efficiently on the whole genome level. This review covers the effects of genetic variations in drug metabolizing enzymes, drug transporters, and direct and indirect interactions with the pharmacological targets/pathways on the individual response to natural products, and provides suggestions on dosing regimen adjustments of natural products based on their pharmacokinetic and pharmacogenetic paratmeters. Finally, we provide our viewpoints on the importance and necessity of pharmacogenetic and pharmacogenomic research of natural products in natural medicine's rational development and clinical application of precision medicine.
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Affiliation(s)
- Tai Rao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, PR China; Institute of Clinical Pharmacology, Central South University, Changsha, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, PR China; National Clinical Research Center for Geriatric Disorders, Changsha, Hunan, PR China
| | - Zhirong Tan
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, PR China; Institute of Clinical Pharmacology, Central South University, Changsha, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, PR China; National Clinical Research Center for Geriatric Disorders, Changsha, Hunan, PR China
| | - Jingbo Peng
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, PR China; Institute of Clinical Pharmacology, Central South University, Changsha, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, PR China; National Clinical Research Center for Geriatric Disorders, Changsha, Hunan, PR China
| | - Ying Guo
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, PR China; Institute of Clinical Pharmacology, Central South University, Changsha, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, PR China; National Clinical Research Center for Geriatric Disorders, Changsha, Hunan, PR China
| | - Yao Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, PR China; Institute of Clinical Pharmacology, Central South University, Changsha, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, PR China; National Clinical Research Center for Geriatric Disorders, Changsha, Hunan, PR China
| | - Honghao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, PR China; Institute of Clinical Pharmacology, Central South University, Changsha, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, PR China; National Clinical Research Center for Geriatric Disorders, Changsha, Hunan, PR China
| | - Dongsheng Ouyang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, PR China; Institute of Clinical Pharmacology, Central South University, Changsha, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, PR China; National Clinical Research Center for Geriatric Disorders, Changsha, Hunan, PR China.
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Li DD, Zhang YH, Zhang W, Zhao P. Meta-Analysis of Randomized Controlled Trials on the Efficacy and Safety of Donepezil, Galantamine, Rivastigmine, and Memantine for the Treatment of Alzheimer's Disease. Front Neurosci 2019; 13:472. [PMID: 31156366 PMCID: PMC6529534 DOI: 10.3389/fnins.2019.00472] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 04/26/2019] [Indexed: 01/02/2023] Open
Abstract
To study the impact of donepezil, rivastigmine, galantamine, and memantine on cognitive, functional, behavioral, global changes and adverse effects in patients with mild, moderate and severe Alzheimer’s disease (AD), we screened the literature published before September 2017 in the Pubmed, Embase, Cochrane library and Web of Science Electronic databases according to the inclusion criteria. Thirty-six studies were finally determined from 1560 preliminary screened articles. The AD Assessment Scale-cognitive Subscale (ADAS-cog), AD Cooperative Study-Activities of Daily Living (ADCS-ADL), Neuropsychiatric Inventory (NPI), and Clinician’s Interview-Based Impression of Change Plus Caregiver Input scale (CIBIC+) were used as valid endpoints. Of the 36 trials included, meta-analyses of these placebo-control trials showed that there were significant differences between the donepezil, rivastigmine and placebo groups using ADAS-cog, ADCS-ADL, and CIBIC+. Meta-analyses of these placebo-controlled trials showed that there were significant differences between the galantamine and placebo groups using ADAS-cog, ADCS-ADL, NPI, and CIBIC+. These observations suggest that memantine is beneficial for stabilizing or slowing the decline in ADAS-cog and ADCS-ADL19 changes in AD patients. However, there was no significant effect according to the ADCS-ADL23, NPI, and CIBIC+ tests, which indicated that memantine treatment has no significant effect on these cognitive aspects of AD patients. Different effects of donepezil, rivastigmine, galantamine, or memantine on AD were found in this study. According to the results, we conclude that galantamine is effective in treating all aspects of AD and is the first choice for the treatment of AD. However, due to limited data, we should consider additional data to obtain more stable results.
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Affiliation(s)
- Dan-Dan Li
- College of Life and Health Sciences, Northeastern University, Shenyang, China
| | - Ya-Hong Zhang
- College of Life and Health Sciences, Northeastern University, Shenyang, China
| | - Wei Zhang
- Department of Hepatobiliary Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Pu Zhao
- College of Life and Health Sciences, Northeastern University, Shenyang, China
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Dekker MJHJ, Bouvy JC, O'Rourke D, Thompson R, Makady A, Jonsson P, Gispen-de Wied CC. Alignment of European Regulatory and Health Technology Assessments: A Review of Licensed Products for Alzheimer's Disease. Front Med (Lausanne) 2019; 6:73. [PMID: 31134200 PMCID: PMC6515927 DOI: 10.3389/fmed.2019.00073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022] Open
Abstract
Aims: To facilitate regulatory learning, we evaluated similarities and differences in evidence requirements between regulatory and health technology assessment (HTA) bodies of Alzheimer's disease (AD) approved products. Methods: The European marketing authorisation application dossiers and European public assessment reports (EPARs) of the licensed AD drugs were screened to identify the phase III randomised controlled trials (RCTs) and outcomes used. We also screened the assessment reports of the National Institute of Health and Care Excellence (NICE, England) and the National Health Care Institute (ZiN, the Netherlands) to identify the studies and outcomes used in HTA assessments. Results: The application dossiers of donepezil, galantamine, rivastigmine, and memantine contained 16 phase III RCTs in total. These trials were also included in HTA assessments except that NICE excluded studies that were not published (n = 2) or trials that included patients with other types of dementia (n = 3). In the regulatory assessments the focus was on cognitive and global outcomes, and to some extent on function. In the HTA assessments of clinical effectiveness other domains were also covered including: function, behaviour and mood, and, occasionally, quality of life. In the economic analyses of NICE the domains cognition, function, and quality of life were included. Conclusion: There was a large overlap in inclusion of trials in regulatory and HTA assessments, although the focus on specific outcomes slightly differed. Understanding the methods and perceptions of both authorities can stimulate regulatory and HTA cross-talk and further alignment, and therefore more rapid patient access to new treatments.
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Affiliation(s)
| | - Jacoline C. Bouvy
- National Institute for Health and Care Excellence, London, United Kingdom
| | - Diana O'Rourke
- National Institute for Health and Care Excellence, Manchester, United Kingdom
| | | | - Amr Makady
- National Health Care Institute, Diemen, Netherlands
| | - Pall Jonsson
- National Institute for Health and Care Excellence, Manchester, United Kingdom
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