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Ueno K, Ishitobi M, Kosaka H, Ichijo K, Nagase Y. Mirtazapine Monotherapy for Antipsychotics-refractory Psychosis in a Patient with Very-late-onset Schizophrenia-like Psychosis: A Case Report. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2024; 22:387-389. [PMID: 38627087 PMCID: PMC11024701 DOI: 10.9758/cpn.23.1103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/12/2023] [Accepted: 09/04/2023] [Indexed: 04/20/2024]
Abstract
Very-late-onset schizophrenia-like psychosis (VLOSLP) is a condition in which psychotic symptoms emerge after the age of 60 years. Given its heterogeneous nature, VLOSLP remains a diagnostic and therapeutic dilemma. Here, we report a case of a 68-year-old patient with psychosis refractory to antipsychotics who was successfully treated with mirtazapine monotherapy. This case suggests that mirtazapine monotherapy may be effective for the treatment of patients with antipsychotic- refractory VLOSLP.
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Affiliation(s)
- Kanji Ueno
- Department of Neuropsychiatry, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | | | - Hirotaka Kosaka
- Department of Neuropsychiatry, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kei Ichijo
- Department of Psychiatry, Takatsuki Hospital, Hachiouji, Japan
| | - Yukihiro Nagase
- Department of Psychiatry, Takatsuki Hospital, Hachiouji, Japan
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Tolea MI, Ezzeddine R, Camacho S, Galvin JE. Emerging drugs for dementia with Lewy Bodies: a review of Phase II & III trials. Expert Opin Emerg Drugs 2023; 28:167-180. [PMID: 37531299 DOI: 10.1080/14728214.2023.2244425] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Despite faster cognitive decline and greater negative impact on patients and family caregivers, drug development efforts in Dementia with Lewy Bodies (DLB) fall behind those for Alzheimer's Disease (AD). Current off-label drug DLB treatment options are limited to symptomatic agents developed to address cognitive deficits in AD, motor deficits in Parkinson's Disease, or behavioral symptoms in psychiatric disease. Aided by recent improvements in DLB diagnosis, a new focus on the development of disease-modifying agents (DMA) is emerging. AREAS COVERED Driven by evidence supporting different pathological mechanisms in DLB and PDD, this review assesses the evidence on symptomatic drug treatments and describes current efforts in DMA development in DLB. Specifically, our goals were to: (1) review evidence supporting the use of symptomatic drug treatments in DLB; (2) review the current DMA pipeline in DLB with a focus on Phase II and III clinical trials; and (3) identify potential issues with the development of DMA in DLB. Included in this review were completed and ongoing drug clinical trials in DLB registered on ClinicalTrials.gov (no time limits set for the search) or disseminated at the 2023 international conference on Clinical Trials in AD. Drug clinical trials registered in non-US clinical trial registries were not included. EXPERT OPINION Adoption of current symptomatic drug treatments used off-label in DLB relied on efficacy of benefits in other disorders rather than evidence from randomized controlled clinical trials. Symptoms remain difficult to manage. Several DMA drugs are currently being evaluated as either repurposing candidates or novel small molecules. Continued improvement in methodological aspects including development of DLB-specific outcome measures and biomarkers is needed to move the field of DMA drug development forward.
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Affiliation(s)
- Magdalena I Tolea
- Comprehensive Center for Brain Health, Lewy Body Dementia Research Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Reem Ezzeddine
- Comprehensive Center for Brain Health, Lewy Body Dementia Research Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Simone Camacho
- Comprehensive Center for Brain Health, Lewy Body Dementia Research Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James E Galvin
- Comprehensive Center for Brain Health, Lewy Body Dementia Research Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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Rothenberg KG, McRae SG, Dominguez-Colman LM, Shutes-David A, Tsuang DW. Pimavanserin Treatment for Psychosis in Patients with Dementia with Lewy Bodies: A Case Series. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e939806. [PMID: 37775968 PMCID: PMC10549935 DOI: 10.12659/ajcr.939806] [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: 02/11/2023] [Revised: 08/11/2023] [Accepted: 07/27/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Many patients with dementia with Lewy bodies (DLB) experience cholinesterase inhibitor- and antipsychotic-resistant psychosis. The new second-generation antipsychotic pimavanserin has been used with some success in the treatment of psychosis in other forms of dementia, including Alzheimer disease and Parkinson disease dementia. It is possible that pimavanserin may also be useful in the treatment of psychosis in DLB. We sought to describe the disease course and treatment of psychosis in 4 patients with DLB who were prescribed pimavanserin after other medications failed to reduce the frequency or severity of hallucinations and delusions. CASE REPORT This is a case series of 4 male patients (ages 56 to 74 at the beginning of the reports) who developed DLB and psychosis (eg, visual illusions, visual and olfactory hallucinations, and paranoid delusions). All 4 patients were prescribed cholinesterase inhibitors (eg, donepezil or rivastigmine) prior to pimavanserin, and only 1 patient experienced improved psychosis while on cholinesterase inhibitors. All 3 patients who were prescribed first-generation antipsychotics (eg, haloperidol) or traditional second-generation antipsychotics (eg, olanzapine, risperidone, or quetiapine) experienced initial or lasting side effects with no improvement of psychosis. Conversely, all 4 patients tolerated pimavanserin well, and 3 of the 4 patients experienced significant improvement of psychosis (eg, fewer hallucinations, fewer delusions, reduced paranoia, and/or reduced distress or agitation related to hallucinations and delusions) when prescribed pimavanserin. CONCLUSIONS This case series suggests that pimavanserin is tolerable in older males with DLB and that it may be useful for the reduction of distressful hallucinations, delusions, and paranoia in patients with DLB.
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Affiliation(s)
- Kasia Gustaw Rothenberg
- Lou Ruvo Center for Brain Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sharon G. McRae
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Liza M. Dominguez-Colman
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Andrew Shutes-David
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Debby W. Tsuang
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Benussi A, Borroni B. Advances in the treatment and management of frontotemporal dementia. Expert Rev Neurother 2023; 23:621-639. [PMID: 37357688 DOI: 10.1080/14737175.2023.2228491] [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: 04/14/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
INTRODUCTION Frontotemporal dementia (FTD) is a complex neurodegenerative disorder, characterized by a wide range of pathological conditions associated with the buildup of proteins such as tau and TDP-43. With a strong hereditary component, FTD often results from genetic variants in three genes - MAPT, GRN, and C9orf72. AREAS COVERED In this review, the authors explore abnormal protein accumulation in FTD and forthcoming treatments, providing a detailed analysis of new diagnostic advancements, including innovative markers. They analyze how these discoveries have influenced therapeutic strategies, particularly disease-modifying treatments, which could potentially transform FTD management. This comprehensive exploration of FTD from its molecular underpinnings to its therapeutic prospects offers a compelling overview of the current state of FTD research. EXPERT OPINION Notable challenges in FTD management involve identifying reliable biomarkers for early diagnosis and response monitoring. Genetic forms of FTD, particularly those linked to C9orf72 and GRN, show promise, with targeted therapies resulting in substantial progress in disease-modifying strategies. The potential of neuromodulation techniques, like tDCS and rTMS, is being explored, requiring further study. Ongoing trials and multi-disciplinary care highlight the continued push toward effective FTD treatments. With increasing understanding of FTD's molecular and clinical intricacies, the hope for developing effective interventions grows.
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Affiliation(s)
- Alberto Benussi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Barbara Borroni
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili di Brescia, Brescia, Italy
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Albujuq NR, Meana JJ, Diez-Alarcia R, Muneta-Arrate I, Naqvi A, Althumayri K, Alsehli M. Design, Synthesis, Molecular Docking, and Biological Evaluation of Novel Pimavanserin-Based Analogues as Potential Serotonin 5-HT 2A Receptor Inverse Agonists. J Med Chem 2023. [PMID: 37378639 DOI: 10.1021/acs.jmedchem.3c00662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
There is concern for important adverse effects with use of second-generation antipsychotics in Parkinson's disease psychosis (PDP) and dementia-related psychosis. Pimavanserin is the only antipsychotic drug authorized for PDP and represents an inverse agonist of 5-HT2A receptors (5-HT2AR) lacking affinity for dopamine receptors. Therefore, the development of serotonin 5-HT2AR inverse agonists without dopaminergic activity represents a challenge for different neuropsychiatric disorders. Using ligand-based drug design, we discovered a novel structure of pimavanserin analogues (2, 3, and 4). In vitro competition receptor binding and functional G protein coupling assays demonstrated that compounds 2, 3, and 4 showed higher potency than pimavanserin as 5-HT2AR inverse agonists in the human brain cortex and recombinant cells. To assess the effect of molecular substituents for selectivity and inverse agonism at 5-HT2ARs, molecular docking and in silico predicted physicochemical parameters were performed. Docking studies were in agreement with in vitro screenings and the results resembled pimavanserin.
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Affiliation(s)
- Nader R Albujuq
- Department of Chemistry, School of Science, The University of Jordan, Amman 11942, Jordan
| | - J Javier Meana
- Department of Pharmacology, University of the Basque Country UPV/EHU, 48940 Leioa, Bizkaia, Spain
- Centro de Investigación Biomédica en Red de Salud Mental CIBERSAM, 48940 Leioa, Bizkaia, Spain
- Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Bizkaia, Spain
| | - Rebeca Diez-Alarcia
- Department of Pharmacology, University of the Basque Country UPV/EHU, 48940 Leioa, Bizkaia, Spain
- Centro de Investigación Biomédica en Red de Salud Mental CIBERSAM, 48940 Leioa, Bizkaia, Spain
- Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Bizkaia, Spain
| | - Itziar Muneta-Arrate
- Department of Pharmacology, University of the Basque Country UPV/EHU, 48940 Leioa, Bizkaia, Spain
- Centro de Investigación Biomédica en Red de Salud Mental CIBERSAM, 48940 Leioa, Bizkaia, Spain
| | - Arshi Naqvi
- Chemistry Department, College of Science, Taibah University, Al Madinah, Al Munwarah 30002, Saudi Arabia
| | - Khalid Althumayri
- Chemistry Department, College of Science, Taibah University, Al Madinah, Al Munwarah 30002, Saudi Arabia
| | - Mosa Alsehli
- Chemistry Department, College of Science, Taibah University, Al Madinah, Al Munwarah 30002, Saudi Arabia
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Pessoa RMDP, Maximiano-Barreto MA, Lambert L, Leite ÉDM, Chagas MHN. The frequency of psychotic symptoms in types of dementia: a systematic review. Dement Neuropsychol 2023; 17:e20220044. [PMID: 37223834 PMCID: PMC10202325 DOI: 10.1590/1980-5764-dn-2022-0044] [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: 05/16/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 05/25/2023] Open
Abstract
The frequency of psychotic symptoms in older adults is high, mainly in neurocognitive cognitions of the most varied etiologies. Objectives This study aimed to review the studies that analyze the frequency of the types of delusions, hallucinations, and misidentifications in dementia conditions of different etiologies. Methods A systematic review was conducted on August 9, 2021, in the PubMed, PsycInfo, Embase, Web of Science, and Scopus databases with the following descriptors: (dementia OR alzheimer disease OR dementia with Lewy bodies OR frontotemporal dementia OR mixed dementia OR vascular dementia OR major neurocognitive disorder OR parkinson disease dementia) AND (psychotic symptoms OR psychosis OR hallucinations OR delusions OR psychopathology OR misidentification) AND (prevalence OR epidemiology). Results A total of 5,077 articles were found, with a final inclusion of 35. The overall frequency of psychotic symptoms ranged from 34 to 63% in dementia conditions of the most varied etiologies. Alzheimer's disease (AD) presents more delusions and hallucinations and has a higher frequency regarding the presence of misidentifications. On the contrary, Dementia with Lewy bodies (DLB) seems to present more hallucinations, even auditory, when compared to the other dementias, concomitantly with delusions. Vascular and frontotemporal dementia present fewer psychotic symptoms than DLB and AD. Conclusions We identified a gap in the literature on the description of the psychotic symptoms of dementia, mainly in those of non-AD etiologies. Studies that assess the neuropsychiatric symptoms of dementias deeply might contribute in a more definite manner to the causal diagnosis of dementia.
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Affiliation(s)
- Rebeca Mendes de Paula Pessoa
- Universidade de São Paulo, Departamento de Neurociências e do Comportamento, Ribeirão Preto SP, Brazil
- Universidade Federal de São Carlos, Grupo de Estudos e Pesquisas em Saúde Mental, Cognição e Envelhecimento, São Carlos SP, Brazil
| | - Madson Alan Maximiano-Barreto
- Universidade Federal de São Carlos, Grupo de Estudos e Pesquisas em Saúde Mental, Cognição e Envelhecimento, São Carlos SP, Brazil
| | | | - Érica Dayanne Meireles Leite
- Universidade de São Paulo, Departamento de Neurociências e do Comportamento, Ribeirão Preto SP, Brazil
- Universidade Federal de São Carlos, Grupo de Estudos e Pesquisas em Saúde Mental, Cognição e Envelhecimento, São Carlos SP, Brazil
| | - Marcos Hortes Nisihara Chagas
- Universidade de São Paulo, Departamento de Neurociências e do Comportamento, Ribeirão Preto SP, Brazil
- Universidade Federal de São Carlos, Grupo de Estudos e Pesquisas em Saúde Mental, Cognição e Envelhecimento, São Carlos SP, Brazil
- Instituto Bairral de Psiquiatria, Itapira SP, Brazil
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Rissardo JP, Durante Í, Sharon I, Fornari Caprara AL. Pimavanserin and Parkinson's Disease Psychosis: A Narrative Review. Brain Sci 2022; 12:1286. [PMID: 36291220 PMCID: PMC9599742 DOI: 10.3390/brainsci12101286] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 10/18/2023] Open
Abstract
Pimavanserin (PMV) is the first approved drug for treating hallucinations and delusions in Parkinson's disease (PD) psychosis. Psychosis is one of the leading causes of nursing home placement in people with PD. Furthermore, hallucinations are a more frequent cause of institutionalization than motor disability or dementia related to PD. The management of PD psychosis involves antipsychotic medications. Most of the drugs in this class directly block dopamine D2 receptors, leading to significantly worsening motor symptoms in patients with PD. The most commonly used medications for managing PD psychosis are quetiapine, clozapine, and PMV. This literature review aims to study pimavanserin's history, mechanism, clinical trials, and post-marketing experience. PMV is a potent 5-HT2A receptor antagonist/inverse agonist. Moreover, this drug can interact with 5-HT2C receptors. We calculated some physicochemical descriptors and pharmacokinetic properties of PMV. Eight clinical trials of PMV and PD psychosis are registered on ClinicalTrials.gov. Only four of them have complete results already published. Meta-analytic results showed that PMV efficacy is inferior to clozapine. However, PMV has a significantly lower number of side-effects for managing psychosis in PD. Medicare database assessment revealed 35% lower mortality with PMV compared to other atypical antipsychotics. Moreover, sensitive statistical analysis demonstrated that PMV is a protective factor for the risk of falls in individuals with PD.
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Affiliation(s)
- Jamir Pitton Rissardo
- Medicine Department, Federal University of Santa Maria, Santa Maria 97105-900, Brazil
| | - Ícaro Durante
- Department of Medicine, Federal University of Fronteira Sul, Passo Fundo 99010-121, Brazil
| | - Idan Sharon
- NewYork-Presbyterian Brooklyn Methodist Hospital, New York, NY 11215, USA
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Brandt T, Frangiosa T, Biggar V, Taylor A, Valentine J, Keller B, Price M, DeMuro C, Abler V. Symptoms and Treatment Needs of People with Dementia-Related Psychosis: A Mixed-Methods Study of the Patient Experience. Clin Gerontol 2022; 45:681-695. [PMID: 34369313 DOI: 10.1080/07317115.2021.1957050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study describes the person-centered experience and impact of symptoms and the treatment needs of dementia-related psychosis (DRP) from a patient and care partner perspective. METHODS Qualitative interviews and a quantitative survey were used to collect patient experience data from persons with DRP or their care partners. RESULTS Sixteen participants (1 person with DRP, 15 care partners) completed the qualitative interview; 212 participants (26 persons with DRP, 186 care partners) completed the quantitative survey. The most commonly reported symptoms were visual hallucinations, auditory hallucinations, persecutory delusions, and distortion of senses. The most common impacts were difficulty differentiating what is real from what is not real, increased anxiety, and effects on personal relationships. Current treatments were less than moderately helpful, and the ability to distinguish what is real from what is not real and overall symptom improvement were described as the most important benefits of an ideal treatment. CONCLUSIONS Patient experience data provide insights into urgent therapeutic needs of patients by describing the nature, frequency, and severity of symptoms and the impacts they have on individuals' lives. CLINICAL IMPLICATIONS Patient experience data demonstrate an unmet need for treatments to reduce the symptoms and impacts of DRP.
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Affiliation(s)
- Teresa Brandt
- Acadia Pharmaceuticals Inc, San Diego, California, USA
| | | | | | - Angela Taylor
- Lewy Body Dementia Association, Lilburn, Georgia, USA
| | - James Valentine
- Hyman, Phelps & McNamara, P.C, Washington, DC, USA.,Carey School of Law, University of Maryland, Baltimore, Maryland, USA
| | - Bill Keller
- Acadia Pharmaceuticals Inc, San Diego, California, USA
| | - Mark Price
- RTI Health Solutions, Research Triangle Park, North Carolina, USA
| | - Carla DeMuro
- RTI Health Solutions, Research Triangle Park, North Carolina, USA
| | - Victor Abler
- Acadia Pharmaceuticals Inc, San Diego, California, USA
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Rashid N, Wetmore JB, Irfan M, Abler V. Economic Evaluation of Healthcare Resource Utilization and Costs for Newly Diagnosed Dementia-Related Psychosis. Geriatrics (Basel) 2022; 7:geriatrics7020029. [PMID: 35314601 PMCID: PMC8938820 DOI: 10.3390/geriatrics7020029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/15/2022] [Accepted: 02/26/2022] [Indexed: 11/16/2022] Open
Abstract
This retrospective cohort study described changes in all-cause healthcare resource utilization (HCRU) and associated costs in dementia patients newly diagnosed with psychosis. Dementia and incident psychosis were identified using diagnostic and pharmacy claims using a Medicare 20% random sample dataset. All-cause HCRU and unweighted and weighted (by person-years of follow-up) HCRU-associated costs were evaluated in the year prior to and the 4 years following diagnosis of psychosis. In 49,509 dementia patients with psychosis, physician visits per patient per year increased from a mean of 26.7 (standard deviation (SD) 20.0) prior to psychosis to 38.4 (SD 41.9) post-psychosis diagnosis. The number of inpatient stay claims increased from 1.0 (SD 1.4) to 1.7 (SD 5.8). Mean unweighted costs for inpatient stays and home healthcare/hospice during 2008–2016 were USD 9989 and USD 3279 prior to a diagnosis of psychosis but increased to USD 25,982 and USD 9901 (weighted: USD 11,779 and USD 6709), respectively, in the year after a psychosis diagnosis. This pattern of a sharp increase in mean costs was also observed in costs adjusted to 2015 USD, and in both unweighted and weighted total and psychosis-related costs. These results indicate the importance of identifying newly diagnosed psychosis in dementia patients as well as the pressing need for management strategies and treatments that can reduce HCRU and costs.
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Affiliation(s)
- Nazia Rashid
- Acadia Pharmaceuticals Inc., San Diego, CA 92130, USA;
- Correspondence: ; Tel.: +1-858-558-2871
| | - James B. Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN 55415, USA;
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN 55404, USA
| | - Muna Irfan
- Veterans Affairs Medical Center, University of Minnesota, Minneapolis, MN 55417, USA;
| | - Victor Abler
- Acadia Pharmaceuticals Inc., San Diego, CA 92130, USA;
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Psychosis in Alzheimer disease - mechanisms, genetics and therapeutic opportunities. Nat Rev Neurol 2022; 18:131-144. [PMID: 34983978 PMCID: PMC9074132 DOI: 10.1038/s41582-021-00597-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 12/14/2022]
Abstract
Psychosis is a common and distressing symptom in people with Alzheimer disease, and few safe and effective treatments are available. However, new approaches to symptom assessment and treatment are beginning to drive the field forward. New nosological perspectives have been provided by incorporating the emergence of psychotic symptoms in older adults - even in advance of dementia - into epidemiological and neurobiological frameworks as well as into diagnostic and research criteria such as the International Psychogeriatric Association criteria for psychosis in neurocognitive disorders, the Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART) research criteria for psychosis in neurodegenerative disease, and the ISTAART criteria for mild behavioural impairment. Here, we highlight the latest findings in genomics, neuroimaging and neurobiology that are informing approaches to drug discovery and repurposing. Current pharmacological and non-pharmacological treatment options are discussed, with a focus on safety and precision medicine. We also explore trial data for pimavanserin, a novel agent that shows promise for the treatment of psychosis in people with dementia, and discuss existing agents that might be useful but need further exploration such as escitalopram, lithium, cholinesterase inhibitors and vitamin D. Although the assessment and management of psychosis in people with dementia remain challenging, new opportunities are providing direction and hope to the field.
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Abstract
Dementia-related psychosis (DRP) is prevalent across dementias and typically manifests as delusions and/or hallucinations. The mechanisms underlying psychosis in dementia are unknown; however, neurobiological and pharmacological evidence has implicated multiple signaling pathways and brain regions. Despite differences in dementia pathology, the neurobiology underlying psychosis appears to involve dysregulation of a cortical and limbic pathway involving serotonergic, gamma-aminobutyric acid ergic, glutamatergic, and dopaminergic signaling. Thus, an imbalance in cortical and mesolimbic excitatory tone may drive symptoms of psychosis. Delusions and hallucinations may result from (1) hyperactivation of pyramidal neurons within the visual cortex, causing visual hallucinations and (2) hyperactivation of the mesolimbic pathway, causing both delusions and hallucinations. Modulation of the 5-HT2A receptor may mitigate hyperactivity at both psychosis-associated pathways. Pimavanserin, an atypical antipsychotic, is a selective serotonin inverse agonist/antagonist at 5-HT2A receptors. Pimavanserin may prove beneficial in treating the hallucinations and delusions of DRP without worsening cognitive or motor function.
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Jimenez H, Adrien L, Wolin A, Eun J, Chang EH, Burstein ES, Gomar J, Davies P, Koppel J. The impact of pimavanserin on psychotic phenotypes and tau phosphorylation in the P301L/COMT- and rTg(P301L)4510 mouse models of Alzheimer's disease. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12247. [PMID: 35128032 PMCID: PMC8804623 DOI: 10.1002/trc2.12247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 11/12/2021] [Accepted: 12/14/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Psychosis in Alzheimer's disease (AD) is associated with grave clinical consequences including a precipitous cognitive decline and a hastened demise. These outcomes are aggravated by use of existing antipsychotic medications, which are also associated with cognitive decline and increased mortality; preclinical models that would develop new therapeutic approaches are desperately needed. The current report evaluates the ability of the neoteric antipsychotic, pimavanserin, to normalize hyperkinesis and sensorimotor gating in the novel catechol-O-methyltransferase (COMT) deleted P301L/COMT- and rTg(P301L)4510 models of psychotic AD, and the impact of pimavanserin on tau pathology. METHODS Female P301L/COMT- mice were behaviorally characterized for abnormalities of locomotion and sensorimotor gating, and biochemically characterized for patterns of tau phosphorylation relative to relevant controls utilizing high-sensitivity tau enzyme-linked immunosorbent assay (ELISA). Female P301L/COMT- and rTg(P301L)4510 mice were randomized to pimavanserin or vehicle treatment to study the ability of pimavanserin to normalize locomotion and rescue sensorimotor gating. Additionally, high-sensitivity tau ELISA was used to investigate the impact of treatment on tau phosphorylation. RESULTS P301L/COMT- mice evidenced a hyperlocomotive phenotype and deficits of sensorimotor gating relative to wild-type mice on the same background, and increased tau phosphorylation relative to COMT-competent P301L mice. Pimavanserin normalized the hyperkinetic phenotype in both the P301L/COMT- and rTg(P301L)4510 mice but had no impact on sensorimotor gating in either model. Pimavanserin treatment had little impact on tau phosphorylation patterns. DISCUSSION These data suggest that pimavanserin ameliorates tau-driven excessive locomotion. Given the morbidity associated with aberrant motor behaviors such as pacing in AD and lack of effective treatments, future studies of the impact of pimavanserin on actigraphy in patients with this syndrome may be warranted.
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Affiliation(s)
- Heidy Jimenez
- Northwell HealthThe Feinstein Institutes for Medical ResearchManhassetNew YorkUSA
| | - Leslie Adrien
- Northwell HealthThe Feinstein Institutes for Medical ResearchManhassetNew YorkUSA
| | - Adam Wolin
- Northwell HealthThe Feinstein Institutes for Medical ResearchManhassetNew YorkUSA
| | - John Eun
- Northwell HealthThe Feinstein Institutes for Medical ResearchManhassetNew YorkUSA
| | - Eric H. Chang
- Northwell HealthThe Feinstein Institutes for Medical ResearchManhassetNew YorkUSA
| | | | - Jesus Gomar
- Northwell HealthThe Feinstein Institutes for Medical ResearchManhassetNew YorkUSA
| | - Peter Davies
- Northwell HealthThe Feinstein Institutes for Medical ResearchManhassetNew YorkUSA
| | - Jeremy Koppel
- Northwell HealthThe Feinstein Institutes for Medical ResearchManhassetNew YorkUSA
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Tatiana-Danai D, John P, Anastasia K, Dimitrios K, Loukas A, Panagiotis I, Efrosini K, Thomas T, Magda T. Non-Pharmacological Interventions for the Hallucinations in Patients with Dementia. A Cross-Over Randomized Controlled Trial. JOURNAL OF CLINICAL CASES & REPORTS 2022; 5:139-148. [PMID: 36061372 PMCID: PMC9438432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Hallucinations is a core characteristic symptom in Lewy Body Dementia (DLB) and Parkinson's Dementia (PDD). It may also appear at the late stages of Alzheimer's disease (AD). They are not easily managed, and they are associated with cognitive decline, earlier institutionalization, increased mortality, and increased caregivers' burden. DESIGN/SETTING This is a cross-over RCT. The participants were randomly assigned in 6 different groups of 10 patients each. PARTICIPANTS 60 dementia patients (different types and stages of dementia). INTERVENTIONS The three non-pharmacological interventions used are: A) Validation therapy (VT) in a Psycho-educational program, B) Reminiscence therapy (RT) and C) Music therapy (MT). Each intervention lasted for 5 days and there was an interval of two days, as a wash-out period (all the interventions had a duration of 3 weeks). MEASUREMENTS The measurements which were used at baseline were: MMSE, ACE-R, GDS, FRSDD and NPI questionnaire at baseline and after each intervention. RESULTS The most effective combination for the reduction of the hallucinations is: VT/Psycho-educational program (p = 0.005), MT (p = 0.007) and RT (p = 0.022). The same combination applies for the caregivers' distress: VT/Psychoeducational program (p = 0.010) - MT (p = 0.023) - RT (p = 0.036). CONCLUSION VT/Psycho-educational program followed by MT, followed by RT is an effective combination of non-pharmacological interventions that can reduce hallucinations in patients with dementia and caregivers' burden. Non-pharmacological interventions should be further examined as an effective alternative for the reduction of the hallucinations in dementia.
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Affiliation(s)
| | | | - Konsta Anastasia
- 1 Department of Psychiatry, Aristotle University of Thessaloniki, Greece
| | - Kazis Dimitrios
- 1 Department of Neurology, Aristotle University of Thessaloniki, Greece
| | | | | | | | - Tegos Thomas
- 1 Department of Neurology, Aristotle University of Thessaloniki, Greece
| | - Tsolaki Magda
- 1 Department of Neurology, Aristotle University of Thessaloniki, Greece
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14
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Sivanandy P, Leey TC, Xiang TC, Ling TC, Wey Han SA, Semilan SLA, Hong PK. Systematic Review on Parkinson's Disease Medications, Emphasizing on Three Recently Approved Drugs to Control Parkinson's Symptoms. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:364. [PMID: 35010624 PMCID: PMC8744877 DOI: 10.3390/ijerph19010364] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 12/20/2022]
Abstract
Parkinson's Disease (PD) is a disease that involves neurodegeneration and is characterised by the motor symptoms which include muscle rigidity, tremor, and bradykinesia. Other non-motor symptoms include pain, depression, anxiety, and psychosis. This disease affects up to ten million people worldwide. The pathophysiology behind PD is due to the neurodegeneration of the nigrostriatal pathway. There are many conventional drugs used in the treatment of PD. However, there are limitations associated with conventional drugs. For instance, levodopa is associated with the on-off phenomenon, and it may induce wearing off as time progresses. Therefore, this review aimed to analyze the newly approved drugs by the United States-Food and Drug Administration (US-FDA) from 2016-2019 as the adjuvant therapy for the treatment of PD symptoms in terms of efficacy and safety. The new drugs include safinamide, istradefylline and pimavanserin. From this review, safinamide is considered to be more efficacious and safer as the adjunct therapy to levodopa as compared to istradefylline in controlling the motor symptoms. In Study 016, both safinamide 50 mg (p = 0.0138) and 100 mg (p = 0.0006) have improved the Unified Parkinson's Disease Rating Scale (UPDRS) part III score as compared to placebo. Improvement in Clinical Global Impression-Change (CGI-C), Clinical Global Impression-Severity of Illness (CGI-S) and off time were also seen in both groups of patients following the morning levodopa dose. Pimavanserin also showed favorable effects in ameliorating the symptoms of Parkinson's Disease Psychosis (PDP). A combination of conventional therapy and non-pharmacological treatment is warranted to enhance the well-being of PD patients.
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Affiliation(s)
- Palanisamy Sivanandy
- Department of Pharmacy Practice, School of Pharmacy, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000, Malaysia
- School of Postgraduate Studies, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000, Malaysia
| | - Tan Choo Leey
- Bachelor of Pharmacy (Hons) Programme, School of Pharmacy, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000, Malaysia; (T.C.L.); (T.C.X.); (T.C.L.); (S.A.W.H.); (S.L.A.S.); (P.K.H.)
| | - Tan Chi Xiang
- Bachelor of Pharmacy (Hons) Programme, School of Pharmacy, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000, Malaysia; (T.C.L.); (T.C.X.); (T.C.L.); (S.A.W.H.); (S.L.A.S.); (P.K.H.)
| | - Tan Chi Ling
- Bachelor of Pharmacy (Hons) Programme, School of Pharmacy, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000, Malaysia; (T.C.L.); (T.C.X.); (T.C.L.); (S.A.W.H.); (S.L.A.S.); (P.K.H.)
| | - Sean Ang Wey Han
- Bachelor of Pharmacy (Hons) Programme, School of Pharmacy, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000, Malaysia; (T.C.L.); (T.C.X.); (T.C.L.); (S.A.W.H.); (S.L.A.S.); (P.K.H.)
| | - Samantha Lia Anak Semilan
- Bachelor of Pharmacy (Hons) Programme, School of Pharmacy, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000, Malaysia; (T.C.L.); (T.C.X.); (T.C.L.); (S.A.W.H.); (S.L.A.S.); (P.K.H.)
| | - Phoon Kok Hong
- Bachelor of Pharmacy (Hons) Programme, School of Pharmacy, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000, Malaysia; (T.C.L.); (T.C.X.); (T.C.L.); (S.A.W.H.); (S.L.A.S.); (P.K.H.)
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15
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Lavigne EG, Buttigieg D, Steinschneider R, Burstein ES. Pimavanserin Promotes Trophic Factor Release and Protects Cultured Primary Dopaminergic Neurons Exposed to MPP+ in a GDNF-Dependent Manner. ACS Chem Neurosci 2021; 12:2088-2098. [PMID: 34032411 DOI: 10.1021/acschemneuro.0c00751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Neurodegeneration and impaired neural development are a common feature of many neuropsychiatric disorders. Second-generation antipsychotics (SGAs) and certain atypical antidepressants display neuroprotective effects. Though these drugs interact with many molecular targets, a common shared attribute is high antagonist potency at 5-HT2A receptors. Pimavanserin is a selective 5-HT2A inverse agonist/antagonist that was recently FDA approved for treating hallucinations and delusions associated with Parkinson's disease. Unlike SGAs, pimavanserin lacks activity at other targets like dopamine, histamine, muscarinic, and adrenergic receptors. To investigate whether selective 5-HT2A inverse agonists have neuroprotective properties, pimavanserin and another selective 5-HT2A inverse agonist, M100907, were applied to primary cultures of dopaminergic neurons treated with 1-methyl-4-phenylpyridinium (MPP+). Both pimavanserin and M100907 protected dopaminergic neurons against MPP+-induced cell death. The neuroprotective effects of pimavanserin required signaling through the extracellular signal-regulated kinase 1/2 pathway, restored mitochondrial function, and reduced oxidative stress. Further investigation showed that pimavanserin promotes the release of brain-derived neurotrophic factor and glial-derived neurotrophic factor (GDNF) and that the neuroprotective effects of pimavanserin were blocked by antibodies to GDNF but not by anti-tyrosine receptor kinase B receptor antibodies. Thus, pimavanserin induces release of neurotrophic factors and protects dopaminergic neurons against MPP+ toxicity in a GDNF-dependent manner.
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Affiliation(s)
| | | | | | - Ethan S. Burstein
- Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, California 92130, United States
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16
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Rashid N, Abler V, Andes S, Citrome L. Real-World Medication Treatment Patterns for Long-Term Care Residents with Dementia-Related Psychosis. Gerontol Geriatr Med 2021; 7:23337214211016565. [PMID: 34104683 PMCID: PMC8172951 DOI: 10.1177/23337214211016565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/19/2021] [Indexed: 01/22/2023] Open
Abstract
Objectives: This study evaluated treatment patterns and factors associated with medication treatment changes in residents with dementia-related psychosis in a long-term care (LTC) setting. Methods: A retrospective database cohort study was conducted using the national PharMerica® database and included dementia residents with or without incident psychosis. Treatment patterns were assessed and a multivariate logistic regression model was used to identify factors associated with any treatment change (discontinuation, switch, or sporadic use) in dementia-related psychosis therapy. Results: Among 11,921 residents with incident dementia-related psychosis, 11,246 (94.3%) were prescribed ≥1 index medication to treat psychosis, including 77.3% who received ≥1 typical or atypical antipsychotic. Treatment change was evaluated during the post-index period: 38.7% of residents with dementia-related psychosis discontinued treatment, 13.9% switched treatments, and 7.9% had sporadic use. Factors associated with treatment change were age ≥65 years, Medicare insurance, and comorbid conditions (anemia, coronary heart disease, diabetes, falls, depression, hypertension, or hyperlipidemia) during the pre-index period. Discussion: Approximately 60% of dementia-related psychosis LTC residents experienced a medication treatment change. This treatment change was associated with higher age and higher comorbidities. Medications that treat symptoms of dementia-related psychosis without adding to safety concerns are needed to facilitate long-term, consistent treatment.
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Cummings J, Lee G, Zhong K, Fonseca J, Taghva K. Alzheimer's disease drug development pipeline: 2021. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12179. [PMID: 34095440 PMCID: PMC8145448 DOI: 10.1002/trc2.12179] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/06/2021] [Accepted: 04/15/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The number of individuals worldwide with Alzheimer's disease (AD) is growing at a rapid rate. New treatments are urgently needed. We review the current pipeline of drugs in clinical trials for the treatment of AD. METHODS We interrogated ClinicalTrials.gov, the federal registry of clinical trials to identify drugs in trials. RESULTS There are 126 agents in 152 trials assessing new therapies for AD: 28 treatments in Phase 3 trials, 74 in Phase 2, and 24 in Phase 1. The majority of drugs in trials (82.5%) target the underlying biology of AD with the intent of disease modification; 10.3% are putative cognitive enhancing agents; and 7.1% are drugs being developed to reduce neuropsychiatric symptoms. DISCUSSION This pipeline analysis shows that target biological processes are more diversified, biomarkers are more regularly used, and repurposed agents are being explored to determine their utility for the treatment of AD.
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Affiliation(s)
- Jeffrey Cummings
- Chambers‐Grundy Center for Transformative NeuroscienceDepartment of Brain HealthSchool of Allied Health Sciences, University of Nevada, Las Vegas (UNLV)Las VegasNevadaUSA
| | | | - Kate Zhong
- Department of Brain HealthSchool of Allied Health SciencesUniversity of Nevada, Las Vegas (UNLV)Las VegasNevadaUSA
| | - Jorge Fonseca
- Howard R. Hughes College of EngineeringDepartment of Computer ScienceUniversity of Nevada, Las Vegas (UNLV)Las VegasNevadaUSA
| | - Kazem Taghva
- Howard R. Hughes College of EngineeringDepartment of Computer ScienceUniversity of Nevada, Las Vegas (UNLV)Las VegasNevadaUSA
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18
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Scheltens P, De Strooper B, Kivipelto M, Holstege H, Chételat G, Teunissen CE, Cummings J, van der Flier WM. Alzheimer's disease. Lancet 2021; 397:1577-1590. [PMID: 33667416 PMCID: PMC8354300 DOI: 10.1016/s0140-6736(20)32205-4] [Citation(s) in RCA: 1409] [Impact Index Per Article: 469.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/21/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022]
Abstract
In this Seminar, we highlight the main developments in the field of Alzheimer's disease. The most recent data indicate that, by 2050, the prevalence of dementia will double in Europe and triple worldwide, and that estimate is 3 times higher when based on a biological (rather than clinical) definition of Alzheimer's disease. The earliest phase of Alzheimer's disease (cellular phase) happens in parallel with accumulating amyloid β, inducing the spread of tau pathology. The risk of Alzheimer's disease is 60-80% dependent on heritable factors, with more than 40 Alzheimer's disease-associated genetic risk loci already identified, of which the APOE alleles have the strongest association with the disease. Novel biomarkers include PET scans and plasma assays for amyloid β and phosphorylated tau, which show great promise for clinical and research use. Multidomain lifestyle-based prevention trials suggest cognitive benefits in participants with increased risk of dementia. Lifestyle factors do not directly affect Alzheimer's disease pathology, but can still contribute to a positive outcome in individuals with Alzheimer's disease. Promising pharmacological treatments are poised at advanced stages of clinical trials and include anti-amyloid β, anti-tau, and anti-inflammatory strategies.
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Affiliation(s)
- Philip Scheltens
- Alzheimer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, Netherlands; Department of Neurology, Amsterdam University Medical Centers, Amsterdam, Netherlands; Life Science Partners, Amsterdam, Netherlands.
| | - Bart De Strooper
- VIB Center for Brain and Disease Research, Leuven, Belgium; KU Leuven Department for Neurology, Leuven, Belgium; Dementia Research Institute, University College London, London, UK
| | - Miia Kivipelto
- Division of Clinical Geriatrics and Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska University Hospital, Stockholm, Sweden; Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Ageing and Epidemiology Research Unit, School of Public Health, Imperial College London, London, UK
| | - Henne Holstege
- Alzheimer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, Netherlands; Department of Clinical Genetics, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Gael Chételat
- Normandie Université, Université de Caen, Institut National de la Santé et de la Recherche Médicale, Groupement d'Intérêt Public Cyceron, Caen, France
| | - Charlotte E Teunissen
- Department of Clinical Chemistry, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Jeffrey Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, University of Nevada, Las Vegas, NV, USA; Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Wiesje M van der Flier
- Alzheimer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, Netherlands; Department of Epidemiology and Datascience, Amsterdam University Medical Centers, Amsterdam, Netherlands
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19
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Cummings J. The Role of Neuropsychiatric Symptoms in Research Diagnostic Criteria for Neurodegenerative Diseases. Am J Geriatr Psychiatry 2021; 29:375-383. [PMID: 32819825 PMCID: PMC7855689 DOI: 10.1016/j.jagp.2020.07.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 01/10/2023]
Abstract
Neuropsychiatric syndromes and symptoms play increasingly important roles in research diagnostic criteria for neurodegenerative disorders. Diagnostic criteria were reviewed including those for dementia, Alzheimer's disease, mild cognitive impairment, mild behavioral impairment, prodromal Alzheimer's disease, dementia with Lewy bodies, prodromal dementia with Lewy bodies, Parkinson's disease, multiple system atrophy, frontotemporal dementia, primary progressive aphasia, progressive supranuclear palsy, corticobasal degeneration, traumatic encephalopathy syndrome, Huntington' disease, amyotrophic lateral sclerorsis. All contemporary research diagnostic criteria for neurodegenerative disorders expect those for Parkinson's disease, primary progressive aphasia, multisystem atrophy and amyotrophic lateral sclerosis include neuropsychiatric phenomena as core diagnostic criteria. There are no disease-specific neuropsychiatric symptoms; apathy and disinhibition are common in tauopathies, and rapid-eye-movement sleep behavioral disorder occurs almost exclusively in synucleinopathies. Neuropsychiatric symptoms and syndromes are increasingly integrated into research diagnostic criteria for neurodegenerative disorders; they require clinician skills for recognition; their biology is better understood as their relationships to cognitive, motor, and autonomic symptoms of neurodegenerative disorders are studied.
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Affiliation(s)
- Jeffrey Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences (JC), University of Nevada Las Vegas; Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV.
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20
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Cummings J. New approaches to symptomatic treatments for Alzheimer's disease. Mol Neurodegener 2021; 16:2. [PMID: 33441154 PMCID: PMC7805095 DOI: 10.1186/s13024-021-00424-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/02/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Successful development of agents that improve cognition and behavior in Alzheimer's disease (AD) is critical to improving the lives of patients manifesting the symptoms of this progressive disorder. DISCUSSION There have been no recent approvals of cognitive enhancing agents for AD. There are currently 6 cognitive enhancers in Phase 2 trials and 4 in phase 3. They represent a variety of novel mechanisms. There has been progress in developing new treatments for neuropsychiatric symptoms in AD with advances in treatment of insomnia, psychosis, apathy, and agitation in AD. There are currently 4 AD-related psychotropic agents in Phase 2 trials and 7 in Phase 3 trials. Many novel mechanisms are being explored for the treatment of cognitive and behavioral targets. Progress in trial designs, outcomes measures, and population definitions are improving trial conduct for symptomatic treatment of AD. CONCLUSIONS Advances in developing new agents for cognitive and behavioral symptoms of AD combined with enhanced trial methods promise to address the unmet needs of patients with AD for improved cognition and amelioration of neuropsychiatric symptoms.
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Affiliation(s)
- Jeffrey Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA.
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21
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Yuede CM, Wallace CE, Davis TA, Gardiner WD, Hettinger JC, Edwards HM, Hendrix RD, Doherty BM, Yuede KM, Burstein ES, Cirrito JR. Pimavanserin, a 5HT 2A receptor inverse agonist, rapidly suppresses Aβ production and related pathology in a mouse model of Alzheimer's disease. J Neurochem 2021; 156:658-673. [PMID: 33278025 DOI: 10.1111/jnc.15260] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/12/2020] [Accepted: 11/25/2020] [Indexed: 12/30/2022]
Abstract
Amyloid-β (Aβ) peptide aggregation into soluble oligomers and insoluble plaques is a precipitating event in the pathogenesis of Alzheimer's disease (AD). Given that synaptic activity can regulate Aβ generation, we postulated that 5HT2A -Rs may regulate Aβ as well. We treated APP/PS1 transgenic mice with the selective 5HT2A inverse agonists M100907 or Pimavanserin systemically and measured brain interstitial fluid (ISF) Aβ levels in real-time using in vivo microdialysis. Both compounds reduced ISF Aβ levels by almost 50% within hours, but had no effect on Aβ levels in 5HT2A -R knock-out mice. The Aβ-lowering effects of Pimavanserin were blocked by extracellular-regulated kinase (ERK) and NMDA receptor inhibitors. Chronic administration of Pimavanserin by subcutaneous osmotic pump to aged APP/PS1 mice significantly reduced CSF Aβ levels and Aβ pathology and improved cognitive function in these mice. Pimavanserin is FDA-approved to treat Parkinson's disease psychosis, and also has been shown to reduce psychosis in a variety of other dementia subtypes including Alzheimer's disease. These data demonstrate that Pimavanserin may have disease-modifying benefits in addition to its efficacy against neuropsychiatric symptoms of Alzheimer's disease. Read the Editorial Highlight for this article on page 560.
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Affiliation(s)
- Carla M Yuede
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Clare E Wallace
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Todd A Davis
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Woodrow D Gardiner
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Jane C Hettinger
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Hannah M Edwards
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Rachel D Hendrix
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Brookelyn M Doherty
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Kayla M Yuede
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | | | - John R Cirrito
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
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22
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Moyron RB, Vallejos PA, Fuller RN, Dean N, Wall NR. Neuroimaging and advanced research techniques may lead to improved outcomes in military members suffering from traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000608. [PMID: 33490604 PMCID: PMC7797256 DOI: 10.1136/tsaco-2020-000608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/07/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Recent military conflicts in Iraq and Afghanistan have resulted in the significant increase in blast-related traumatic brain injury (TBI), leading to increased Department of Defense interest in its potential long-term effects ranging from the mildest head injuries termed subconcussive trauma to the most debilitating termed chronic traumatic encephalopathy (CTE). Most patients with mild TBI will recover quickly while others report persistent symptoms called postconcussive syndrome. Repeated concussive and subconcussive head injuries result in neurodegenerative conditions that may hinder the injured for years. Fundamental questions about the nature of these injuries and recovery remain unanswered. Clinically, patients with CTE present with either affective changes or cognitive impairment. Genetically, there have been no clear risk factors identified. The discovery that microglia of the cerebral cortex discharged small extracellular vesicles in the injured and adjacent regions to a TBI may soon shed light on the immediate impact injury mechanisms. The combination of neuroimaging and advanced research techniques may, one day, fill critical knowledge gaps and lead to significant TBI research and treatment advancements.
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Affiliation(s)
- Ron B Moyron
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Paul A Vallejos
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Ryan N Fuller
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Natasha Dean
- Department of Biology, La Sierra University, Riverside, California, USA
| | - Nathan R Wall
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
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23
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Burstein ES. Relevance of 5-HT 2A Receptor Modulation of Pyramidal Cell Excitability for Dementia-Related Psychosis: Implications for Pharmacotherapy. CNS Drugs 2021; 35:727-741. [PMID: 34224112 PMCID: PMC8310514 DOI: 10.1007/s40263-021-00836-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 01/05/2023]
Abstract
Psychosis occurs across a wide variety of dementias with differing etiologies, including Alzheimer's dementia, Parkinson's dementia, Lewy body dementia, frontotemporal dementia, and vascular dementia. Pimavanserin, a selective serotonin 5-HT2A receptor (5-HT2AR) inverse agonist, has shown promising results in clinical trials by reducing the frequency and/or severity of hallucinations and delusions and the risk of relapse of these symptoms in patients with dementia-related psychosis. A literature review was conducted to identify mechanisms that explain the role of 5-HT2ARs in both the etiology and treatment of dementia-related psychosis. This review revealed that most pathological changes commonly associated with neurodegenerative diseases cause one or more of the following events to occur: reduced synaptic contact of gamma aminobutyric acid (GABA)-ergic interneurons with glutamatergic pyramidal cells, reduced cortical innervation from subcortical structures, and altered 5-HT2AR expression levels. Each of these events promotes increased pyramidal cell hyperexcitability and disruption of excitatory/inhibitory balance, facilitating emergence of psychotic behaviors. The brain regions affected by these pathological changes largely coincide with areas expressing high levels of 5-HT2ARs. At the cellular level, 5-HT2ARs are most highly expressed on cortical glutamatergic pyramidal cells, where they regulate pyramidal cell excitability. The common effects of different neurodegenerative diseases on pyramidal cell excitability together with the close anatomical and functional connection of 5-HT2ARs to pyramidal cell excitability may explain why suppressing 5-HT2AR activity could be an effective strategy to treat dementia-related psychosis.
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Affiliation(s)
- Ethan S. Burstein
- Acadia Pharmaceuticals Inc, 12830 El Camino Real, Suite 400, San Diego, CA 92130 USA
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24
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Cummings J. Drug Development for Psychotropic, Cognitive-Enhancing, and Disease-Modifying Treatments for Alzheimer's Disease. J Neuropsychiatry Clin Neurosci 2020; 33:3-13. [PMID: 33108950 PMCID: PMC7989572 DOI: 10.1176/appi.neuropsych.20060152] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disorder with limited available therapies. There is progress in developing treatments for neuropsychiatric indications in AD, including agitation, psychosis, apathy, and sleep disorders. Candidate therapies progress from nonclinical and animal assessment to trials in normal volunteers (phase 1), small phase-2 trials, and larger confirmatory phase-3 trials. Biomarkers play an increasingly important role in selecting participants, stratifying populations, demonstrating target engagement, supporting disease modification, and monitoring safety. There are currently 121 agents in clinical trials, including treatments for neuropsychiatric symptoms, cognition enhancement, and disease progression. There are 27 agents in phase-1 trials, 65 in phase-2 trials, and 29 in phase-3 trials. Most of the agents in trials (80%) target disease modification. Treatments are being assessed in secondary prevention trials with cognitively normal individuals at high risk for the development of AD. There is progress in target diversification, trial designs, outcome measures, biomarkers, and trial population definitions that promise to accelerate developing new therapies for those with or at risk for AD.
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Affiliation(s)
- Jeffrey Cummings
- The Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas, and the Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas
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Abstract
Clinicians should use a systematic approach to evaluating patients presenting with a concern for cognitive impairment. This approach includes interviewing a knowledgeable informant and performing a thorough mental status examination in order to determine the presence of functional impairments and the domains of cognition that are impaired. The results of this interview and examination determine the next steps of the diagnostic work-up. The pattern of cognitive impairment shapes the differential diagnosis. Treatment should address symptoms, and environmental, psychological, and behavioral interventions are essential.
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Affiliation(s)
- Lauren McCollum
- Penn Memory Center, University of Pennsylvania, Philadelphia, PA, USA; Ralston House, Penn Memory Center, ATTN: Maria Crudele, 3615 Chestnut Street, Philadelphia, PA 19104-2612, USA.
| | - Jason Karlawish
- Ralston House, Penn Memory Center, ATTN: Maria Crudele, 3615 Chestnut Street, Philadelphia, PA 19104-2612, USA; Division of Geriatrics, Penn Memory Center, University of Pennsylvania, Philadelphia, PA, USA. https://twitter.com/jasonkarlawish
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Bauzon J, Lee G, Cummings J. Repurposed agents in the Alzheimer's disease drug development pipeline. Alzheimers Res Ther 2020; 12:98. [PMID: 32807237 PMCID: PMC7433208 DOI: 10.1186/s13195-020-00662-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/29/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Treatments are needed to address the growing prevalence of Alzheimer's disease (AD). Clinical trials have failed to produce any AD drugs for Food and Drug Administration (FDA) approval since 2003, and the pharmaceutical development process is both time-consuming and costly. Drug repurposing provides an opportunity to accelerate this process by investigating the AD-related effects of agents approved for other indications. These drugs have known safety profiles, pharmacokinetic characterization, formulations, doses, and manufacturing processes. METHODS We assessed repurposed AD therapies represented in Phase I, Phase II, and Phase III of the current AD pipeline as registered on ClinicalTrials.gov as of February 27, 2020. RESULTS We identified 53 clinical trials involving 58 FDA-approved agents. Seventy-eight percent of the agents in trials had putative disease-modifying mechanisms of action. Of the repurposed drugs in the pipeline 20% are hematologic-oncologic agents, 18% are drugs derived from cardiovascular indications, 14% are agents with psychiatric uses, 12% are drug used to treat diabetes, 10% are neurologic agents, and the remaining 26% of drugs fall under other conditions. Intellectual property strategies utilized in these programs included using the same drug but altering doses, routes of administration, or formulations. Most repurposing trials were supported by Academic Medical Centers and were not funded through the biopharmaceutical industry. We compared our results to a European trial registry and found results similar to those derived from ClinicalTrials.gov. CONCLUSIONS Drug repurposing is a common approach to AD drug development and represents 39% of trials in the current AD pipeline. Therapies from many disease areas provide agents potentially useful in AD. Most of the repurposed agents are generic and a variety of intellectual property strategies have been adopted to enhance their economic value.
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Affiliation(s)
- Justin Bauzon
- School of Medicine, University of Nevada, Las Vegas (UNLV), Las Vegas, NV, 89154, USA
| | - Garam Lee
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, 89106, USA
| | - Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, 89106, USA.
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada, Las Vegas (UNLV), Las Vegas, NV, 89154, USA.
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Cummings J, Lee G, Ritter A, Sabbagh M, Zhong K. Alzheimer's disease drug development pipeline: 2020. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12050. [PMID: 32695874 PMCID: PMC7364858 DOI: 10.1002/trc2.12050] [Citation(s) in RCA: 208] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Alzheimer's disease (AD) is a growing public health concern affecting millions of patients worldwide and costing billions of dollars annually. We review the pipeline of drugs and biologics in clinical trials for the treatment of AD. We use the Common Alzheimer's and Related Dementias Research Ontology (CADRO) to classify treatment targets and mechanisms of action. We review our annual pipeline reports for the past 5 years to provide longitudinal insight into clinical trials and drug development for AD. METHODS We reviewed ClinicalTrials.gov as of February 27, 2020, and identified all trials of pharmacologic agents currently being developed for treatment of AD as represented on this widely used U.S. Food and Drug Administration registry. RESULTS There are 121 agents in clinical trials for the treatment of AD. Twenty-nine agents are in 36 Phase 3 trials, 65 agents are in 73 Phase 2 trials, and 27 agents are in 27 Phase 1 trials. Twelve agents in trials target cognitive enhancement and 12 are intended to treat neuropsychiatric and behavioral symptoms. There are 97 agents in disease modification trials. Compared to the 2019 pipeline, there is an increase in the number of disease-modifying agents targeting pathways other than amyloid or tau. DISCUSSION The 2020 pipeline has innovations in clinical trials and treatment targets that provide hope for greater success in AD drug development programs. Review of clinical trials over the past 5 years show that there is progressive emphasis on non-amyloid targets, including candidate treatments for inflammation, synapse and neuronal protection, vascular factors, neurogenesis, and epigenetic interventions. There has been a marked growth in repurposed agents in the pipeline.
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Affiliation(s)
- Jeffrey Cummings
- Chambers‐Grundy Center for Transformative Neuroscience, Department of Brain HealthSchool of Integrated Health SciencesUniversity of Nevada, Las Vegas (UNLV)Las VegasNevadaUSA
- Cleveland Clinic Lou Ruvo Center for Brain HealthLas VegasNevadaUSA
| | - Garam Lee
- Cleveland Clinic Lou Ruvo Center for Brain HealthLas VegasNevadaUSA
| | - Aaron Ritter
- Cleveland Clinic Lou Ruvo Center for Brain HealthLas VegasNevadaUSA
| | - Marwan Sabbagh
- Cleveland Clinic Lou Ruvo Center for Brain HealthLas VegasNevadaUSA
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Caraci F, Santagati M, Caruso G, Cannavò D, Leggio GM, Salomone S, Drago F. New antipsychotic drugs for the treatment of agitation and psychosis in Alzheimer's disease: focus on brexpiprazole and pimavanserin. F1000Res 2020; 9. [PMID: 32695312 PMCID: PMC7344175 DOI: 10.12688/f1000research.22662.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 12/17/2022] Open
Abstract
Behavioral and psychological symptoms of dementia are symptoms of disturbed perception, mood, behavior, and thought content that occurred frequently. These symptoms, which include apathy, depression, anxiety, psychosis, agitation, and aggression, can serve as predictors of and early clinical diagnostic markers for Alzheimer's disease (AD) and are common precipitants of institutional care. Agitation and psychosis are associated with accelerated disease progression and increased tau phosphorylation in patients with AD. Current guidelines recommend the use of second-generation antipsychotics for the treatment of agitation and psychosis in AD, but only after first-line non-pharmacological interventions and for no longer than 12 weeks because long-term use of these drugs is associated with an increased risk of mortality and an increased frequency of cerebrovascular events. Therefore, new antipsychotic drugs with improved efficacy and safety are needed as an alternative to current antipsychotic drugs. In this report, we discuss some of the most relevant advances in the field of agitation and psychosis in AD and focus on the recent positive clinical evidence observed with two new antipsychotics drugs: brexpiprazole and pimavanserin. Brexpiprazole is a receptor partial agonist (D2, D3, 5-HT1A), receptor antagonist (5-HT2A/B, α1B/α2C) according to the neuroscience-based nomenclature. Two recent phase III clinical trials have shown that brexpiprazole 2 mg/day is effective for the treatment of agitation in patients with AD and has an improved tolerability and safety profile compared with currently available second-generation antipsychotics. Pimavanserin is a receptor antagonist (5-HT2A, 5-HT2C) that has been given market authorization for psychosis occurring in Parkinson's disease. Recent phase II studies suggest that this drug is effective in AD patients with more severe psychosis, although further long-term studies are needed to better define the efficacy and long-term safety profile of pimavanserin for the treatment of psychosis in AD.
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Affiliation(s)
- Filippo Caraci
- Department of Drug Sciences, University of Catania, Viale Andrea Doria 6, 95125, Catania, Italy.,Oasi Research Institute - IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Mario Santagati
- ASP3 Catania, Department of Mental Health, Alzheimer Psychogeriatric Center Corso Italia 234, 95127, Catania, Italy
| | - Giuseppe Caruso
- Oasi Research Institute - IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Dario Cannavò
- ASP3 Catania, Department of Mental Health, Alzheimer Psychogeriatric Center Corso Italia 234, 95127, Catania, Italy
| | - Gian Marco Leggio
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 89, 95123, Catania, Italy
| | - Salvatore Salomone
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 89, 95123, Catania, Italy
| | - Filippo Drago
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 89, 95123, Catania, Italy
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O'Brien J, Taylor JP, Ballard C, Barker RA, Bradley C, Burns A, Collerton D, Dave S, Dudley R, Francis P, Gibbons A, Harris K, Lawrence V, Leroi I, McKeith I, Michaelides M, Naik C, O'Callaghan C, Olsen K, Onofrj M, Pinto R, Russell G, Swann P, Thomas A, Urwyler P, Weil RS, Ffytche D. Visual hallucinations in neurological and ophthalmological disease: pathophysiology and management. J Neurol Neurosurg Psychiatry 2020; 91:512-519. [PMID: 32213570 PMCID: PMC7231441 DOI: 10.1136/jnnp-2019-322702] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/20/2020] [Accepted: 02/20/2020] [Indexed: 12/14/2022]
Abstract
Visual hallucinations are common in older people and are especially associated with ophthalmological and neurological disorders, including dementia and Parkinson's disease. Uncertainties remain whether there is a single underlying mechanism for visual hallucinations or they have different disease-dependent causes. However, irrespective of mechanism, visual hallucinations are difficult to treat. The National Institute for Health Research (NIHR) funded a research programme to investigate visual hallucinations in the key and high burden areas of eye disease, dementia and Parkinson's disease, culminating in a workshop to develop a unified framework for their clinical management. Here we summarise the evidence base, current practice and consensus guidelines that emerged from the workshop.Irrespective of clinical condition, case ascertainment strategies are required to overcome reporting stigma. Once hallucinations are identified, physical, cognitive and ophthalmological health should be reviewed, with education and self-help techniques provided. Not all hallucinations require intervention but for those that are clinically significant, current evidence supports pharmacological modification of cholinergic, GABAergic, serotonergic or dopaminergic systems, or reduction of cortical excitability. A broad treatment perspective is needed, including carer support. Despite their frequency and clinical significance, there is a paucity of randomised, placebo-controlled clinical trial evidence where the primary outcome is an improvement in visual hallucinations. Key areas for future research include the development of valid and reliable assessment tools for use in mechanistic studies and clinical trials, transdiagnostic studies of shared and distinct mechanisms and when and how to treat visual hallucinations.
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Affiliation(s)
- John O'Brien
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - John Paul Taylor
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Clive Ballard
- University of Exeter Medical School, Medical School Building, St Luke's Campus, Exeter, UK
| | - Roger A Barker
- Department of Clinical Neurosciences, WT-MRC Cambridge Stem Cell Institute, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Clare Bradley
- Health Psychology Research Ltd, Egham, Surrey, UK.,Health Psychology Research Unit, Royal Holloway University of London, Egham, Surrey, UK
| | - Alistair Burns
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Daniel Collerton
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sonali Dave
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, London, UK
| | - Rob Dudley
- Gateshead Early Intervention in Psychosis Service, Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, Gateshead, UK
| | - Paul Francis
- University of Exeter Medical School, Medical School Building, St Luke's Campus, Exeter, UK.,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, London, UK
| | - Andrea Gibbons
- Health Psychology Research Unit, Royal Holloway University of London, Egham, Surrey, UK
| | - Kate Harris
- Department of Clinical Neurosciences, WT-MRC Cambridge Stem Cell Institute, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Vanessa Lawrence
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, London, UK
| | - Iracema Leroi
- Global Brain Health Institute, Department of Psychiatry, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Ian McKeith
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michel Michaelides
- Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Chaitali Naik
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Claire O'Callaghan
- Brain and Mind Centre and Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kirsty Olsen
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Marco Onofrj
- Clinical Neurologica, Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, Università G.D'Annunzio, Chieti-Pescara, Italy
| | - Rebecca Pinto
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, London, UK
| | - Gregor Russell
- Bradford District Care NHS Foundation Trust, Lynfield Mount Hospital, Bradford, UK
| | - Peter Swann
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Alan Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Prabitha Urwyler
- Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland.,University Neurorehabilitation Unit, Department of Neurology, University Hospital Inselspital, Bern, Switzerland
| | | | - Dominic Ffytche
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, London, UK
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Cytochrome P450 (CYP450) Interactions Involving Atypical Antipsychotics are Common in Community-Dwelling Older Adults Treated for Behavioral and Psychological Symptoms of Dementia. PHARMACY 2020; 8:pharmacy8020063. [PMID: 32276526 PMCID: PMC7355621 DOI: 10.3390/pharmacy8020063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/11/2022] Open
Abstract
Treatment of behavioral and psychological symptoms of dementia (BPSD) and comorbidities often necessitates the concomitant use of antipsychotics and non-antipsychotic drugs, thereby potentiating the risk for drug–drug interactions (DDIs). The primary objective of our study was to identify potentially clinically relevant cytochrome P450 (CYP)-mediated DDIs involving antipsychotics among participants enrolled in the Program of All-Inclusive Care for the Elderly (PACE) with BPSD. Additionally, we wanted to determine the prevalence of antipsychotic use in this population. The study included 10,001 PACE participants. The practice setting used a proprietary clinical decision support system (CDSS) to analyze simultaneous multidrug interactions. A retrospective analysis of pharmacy claims data was conducted to identify DDIs involving antipsychotics prescribed for BPSD, using snapshots of medication profiles paired with the CDSS. Of the participants who met inclusion criteria, 1190 (11.9%) were prescribed an antipsychotic; of those, 1071 (90.0%) were prescribed an atypical antipsychotic. Aripiprazole commonly caused (being a perpetrator drug 94.6% of the time) potential DDIs with antidepressants (e.g., duloxetine, venlafaxine, mirtazapine), opioids (e.g., hydrocodone, oxycodone, tramadol) and metoprolol via the CYP2D6 isoform. Risperidone commonly caused (85.7%) potential DDIs with donepezil, lamotrigine and trazodone via the CYP3A4 isoform. Quetiapine exclusively suffered (100%) from potential DDIs with amlodipine, buspirone, omeprazole or topiramate via the CYP3A4 isoform. Antipsychotics are commonly prescribed to PACE participants for BPSD treatment and they may interact with other drugs used to treat comorbidities. A thorough review of concomitant medications will help mitigate the likelihood of potentially dangerous CYP-mediated DDIs involving antipsychotics.
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Yunusa I, El Helou ML, Alsahali S. Pimavanserin: A Novel Antipsychotic With Potentials to Address an Unmet Need of Older Adults With Dementia-Related Psychosis. Front Pharmacol 2020; 11:87. [PMID: 32174828 PMCID: PMC7054448 DOI: 10.3389/fphar.2020.00087] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/27/2020] [Indexed: 01/09/2023] Open
Abstract
Dementia affects more than 40 million people worldwide. When it is accompanied by psychosis, symptom management is especially challenging. Although no drug has been approved by the US Food and Drug Administration (FDA) for psychosis in patients with dementia, atypical antipsychotics are used off-label in severe cases in patients who do not respond to non-pharmacological interventions. However, antipsychotic use in elderly patients with dementia-related psychosis (DRP) is associated with adverse reactions including motor function disorders, cognitive impairment, cerebrovascular events, and increased risk of death. In 2017, the US FDA granted breakthrough therapy designation to the new antipsychotic pimavanserin for the treatment of DRP. Topline result of the pivotal phase III HARMONY (NCT03325556) trial suggests that pimavanserin reduces the relapse of psychosis by 2.8-folds compared to placebo. This favorable result may open path for the potential approval of pimavanserin in DRP. In this review, we discuss the pharmacological activity, clinical efficacy and safety of pimavanserin as a novel atypical antipsychotic with potentials to address the unmet needs of older adults with DRP.
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Affiliation(s)
- Ismaeel Yunusa
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | | | - Saud Alsahali
- Unaiz College of Pharmacy, Qassim University, Qassim, Saudi Arabia
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Cummings J. The Role of Biomarkers in Alzheimer's Disease Drug Development. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1118:29-61. [PMID: 30747416 DOI: 10.1007/978-3-030-05542-4_2] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Biomarkers have a key role in Alzheimer's disease (AD) drug development. Biomarkers can assist in diagnosis, demonstrate target engagement, support disease modification, and monitor for safety. The amyloid (A), tau (T), neurodegeneration (N) Research Framework emphasizes brain imaging and CSF measures relevant to disease diagnosis and staging and can be applied to drug development and clinical trials. Demonstration of target engagement in Phase 2 is critical before advancing a treatment candidate to Phase 3. Trials with biomarker outcomes are shorter and smaller than those required to show clinical benefit and are important to understanding the biological impact of an agent and inform go/no-go decisions. Companion diagnostics are required for safe and effective use of treatments and may emerge in AD drug development programs. Complementary biomarkers inform the use of therapies but are not mandatory for use. Biomarkers promise to de-risk AD drug development, attract sponsors to AD research, and accelerate getting new drugs to those with or at risk for AD.
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Affiliation(s)
- Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA.
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