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Klein EG, Schroeder K, Wessels AM, Phipps A, Japha M, Schilling T, Zimmer JA. How donanemab data address the coverage with evidence development questions. Alzheimers Dement 2024; 20:3127-3140. [PMID: 38323738 PMCID: PMC11032520 DOI: 10.1002/alz.13700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 02/08/2024]
Abstract
The Centers for Medicare & Medicaid Services (CMS) established a class-based National Coverage Determination (NCD) for monoclonal antibodies directed against amyloid for Alzheimer's disease (AD) with patient access through Coverage with Evidence Development (CED) based on three questions. This review, focused on donanemab, answers each of these CED questions with quality evidence. TRAILBLAZER-ALZ registration trials are presented with supporting literature and real-world data to answer CED questions for donanemab. TRAILBLAZER-ALZ registration trials demonstrated that donanemab significantly slowed cognitive and functional decline in amyloid-positive early symptomatic AD participants, and lowered their risk of disease progression while key safety risks occurred primarily within the first 6 months and then declined. Donanemab meaningfully improved health outcomes with a manageable safety profile in an early symptomatic AD population, representative of Medicare populations across diverse practice settings. The donanemab data provide the necessary level of evidence for CMS to open a reconsideration of their NCD. HIGHLIGHTS: Donanemab meaningfully improved outcomes in trial participants with early symptomatic Alzheimer's disease. Comorbidities in trial participants were consistent with the Medicare population. Co-medications in trial participants were consistent with the Medicare population. Risks associated with treatment tended to occur in the first 6 months. Risks of amyloid-related imaging abnormalities were managed with careful observation and magnetic resonance imaging monitoring.
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Affiliation(s)
- Eric G. Klein
- Global Medical Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Krista Schroeder
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Alette M. Wessels
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Adam Phipps
- Lilly Value and Access, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Maureen Japha
- Corporate Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Traci Schilling
- Global Medical Affairs, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
| | - Jennifer A. Zimmer
- Research and Development, Eli Lilly and CompanyLilly Corporate CenterIndianapolisIndianaUSA
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Sims JR, Zimmer JA, Evans CD, Lu M, Ardayfio P, Sparks J, Wessels AM, Shcherbinin S, Wang H, Monkul Nery ES, Collins EC, Solomon P, Salloway S, Apostolova LG, Hansson O, Ritchie C, Brooks DA, Mintun M, Skovronsky DM. Donanemab in Early Symptomatic Alzheimer Disease: The TRAILBLAZER-ALZ 2 Randomized Clinical Trial. JAMA 2023; 330:512-527. [PMID: 37459141 PMCID: PMC10352931 DOI: 10.1001/jama.2023.13239] [Citation(s) in RCA: 276] [Impact Index Per Article: 276.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
Importance There are limited efficacious treatments for Alzheimer disease. Objective To assess efficacy and adverse events of donanemab, an antibody designed to clear brain amyloid plaque. Design, Setting, and Participants Multicenter (277 medical research centers/hospitals in 8 countries), randomized, double-blind, placebo-controlled, 18-month phase 3 trial that enrolled 1736 participants with early symptomatic Alzheimer disease (mild cognitive impairment/mild dementia) with amyloid and low/medium or high tau pathology based on positron emission tomography imaging from June 2020 to November 2021 (last patient visit for primary outcome in April 2023). Interventions Participants were randomized in a 1:1 ratio to receive donanemab (n = 860) or placebo (n = 876) intravenously every 4 weeks for 72 weeks. Participants in the donanemab group were switched to receive placebo in a blinded manner if dose completion criteria were met. Main Outcomes and Measures The primary outcome was change in integrated Alzheimer Disease Rating Scale (iADRS) score from baseline to 76 weeks (range, 0-144; lower scores indicate greater impairment). There were 24 gated outcomes (primary, secondary, and exploratory), including the secondary outcome of change in the sum of boxes of the Clinical Dementia Rating Scale (CDR-SB) score (range, 0-18; higher scores indicate greater impairment). Statistical testing allocated α of .04 to testing low/medium tau population outcomes, with the remainder (.01) for combined population outcomes. Results Among 1736 randomized participants (mean age, 73.0 years; 996 [57.4%] women; 1182 [68.1%] with low/medium tau pathology and 552 [31.8%] with high tau pathology), 1320 (76%) completed the trial. Of the 24 gated outcomes, 23 were statistically significant. The least-squares mean (LSM) change in iADRS score at 76 weeks was -6.02 (95% CI, -7.01 to -5.03) in the donanemab group and -9.27 (95% CI, -10.23 to -8.31) in the placebo group (difference, 3.25 [95% CI, 1.88-4.62]; P < .001) in the low/medium tau population and -10.2 (95% CI, -11.22 to -9.16) with donanemab and -13.1 (95% CI, -14.10 to -12.13) with placebo (difference, 2.92 [95% CI, 1.51-4.33]; P < .001) in the combined population. LSM change in CDR-SB score at 76 weeks was 1.20 (95% CI, 1.00-1.41) with donanemab and 1.88 (95% CI, 1.68-2.08) with placebo (difference, -0.67 [95% CI, -0.95 to -0.40]; P < .001) in the low/medium tau population and 1.72 (95% CI, 1.53-1.91) with donanemab and 2.42 (95% CI, 2.24-2.60) with placebo (difference, -0.7 [95% CI, -0.95 to -0.45]; P < .001) in the combined population. Amyloid-related imaging abnormalities of edema or effusion occurred in 205 participants (24.0%; 52 symptomatic) in the donanemab group and 18 (2.1%; 0 symptomatic during study) in the placebo group and infusion-related reactions occurred in 74 participants (8.7%) with donanemab and 4 (0.5%) with placebo. Three deaths in the donanemab group and 1 in the placebo group were considered treatment related. Conclusions and Relevance Among participants with early symptomatic Alzheimer disease and amyloid and tau pathology, donanemab significantly slowed clinical progression at 76 weeks in those with low/medium tau and in the combined low/medium and high tau pathology population. Trial Registration ClinicalTrials.gov Identifier: NCT04437511.
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Affiliation(s)
| | | | | | - Ming Lu
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | | | | | - Hong Wang
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | - Paul Solomon
- Boston Center for Memory and Boston University Alzheimer’s Disease Center, Boston, Massachusetts
| | - Stephen Salloway
- Department of Neurology and Department of Psychiatry, Alpert Medical School of Brown University, Providence, Rhode Island
- Butler Hospital, Providence, Rhode Island
| | - Liana G. Apostolova
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Oskar Hansson
- Clinical Memory Research Unit, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden; Memory Clinic, Skåne University Hospital, Lund, Sweden
| | | | | | - Mark Mintun
- Eli Lilly and Company, Indianapolis, Indiana
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3
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Willis BA, Lowe SL, Monk SA, Cocke PJ, Aluise CD, Boggs LN, Borders AR, Brier RA, Dean RA, Green SJ, James DE, Jhee SS, Lin Q, Lo AC, May PC, Watson BM, Winneroski LL, Yang Z, Zimmer JA, McKinzie DL, Mergott DJ. Robust Pharmacodynamic Effect of LY3202626, a Central Nervous System Penetrant, Low Dose BACE1 Inhibitor, in Humans and Nonclinical Species. J Alzheimers Dis Rep 2022; 6:1-15. [PMID: 35243208 PMCID: PMC8842743 DOI: 10.3233/adr-210037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/19/2021] [Indexed: 11/15/2022] Open
Abstract
Background: The development of beta-site amyloid-beta precursor protein cleaving enzyme (BACE) 1 inhibitors for the treatment of Alzheimer’s disease requires optimization of inhibitor potency, selectivity, and brain penetration. Moreover, there is a need for low-dose compounds since liver toxicity was found with some BACE inhibitors. Objective: To determine whether the high in vitro potency and robust pharmacodynamic effect of the BACE inhibitor LY3202626 observed in nonclinical species translated to humans. Methods: The effect of LY3202626 versus vehicle on amyloid-β (Aβ) levels was evaluated in a series of in vitro assays, as well as in in vivo and multi-part clinical pharmacology studies. Aβ levels were measured using analytical biochemistry assays in brain, plasma, and cerebrospinal fluid (CSF) of mice, dogs and humans. Nonclinical data were analyzed using an ANOVA followed by Tukey’s post hoc test and clinical data used summary statistics. Results: LY3202626 exhibited significant human BACE1 inhibition, with an IC50 of 0.615±0.101 nM in a fluorescence resonance energy transfer assay and an EC50 of 0.275±0.176 nM for lowering Aβ1–40 and 0.228±0.244 nM for Aβ1–42 in PDAPP neuronal cultures. In dogs, CSF Aβ1hboxx concentrations were significantly reduced by ∼80% at 9 hours following a 1.5 mg/kg dose. In humans, CSF Aβ1–42 was reduced by 73.1±7.96 % following administration of 6 mg QD. LY3202626 was found to freely cross the blood-brain barrier in dogs and humans. Conclusion: LY3202626 is a potent BACE1 inhibitor with high blood-brain barrier permeability. The favorable safety and pharmacokinetic/pharmacodynamic profile of LY3202626 supports further clinical development.
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Affiliation(s)
- Brian A. Willis
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Stephen L. Lowe
- Lilly Centre for Clinical Pharmacology, Singapore, Singapore
| | - Scott A. Monk
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Patrick J. Cocke
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Leonard N. Boggs
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Anthony R. Borders
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Richard A. Brier
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Robert A. Dean
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Steven J. Green
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Douglas E. James
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Qun Lin
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Albert C. Lo
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Patrick C. May
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Brian M. Watson
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Zhixiang Yang
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Jennifer A. Zimmer
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - David L. McKinzie
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Dustin J. Mergott
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
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Chandler J, Zimmer JA, Kubisiak E, Kubisiak J. Health care utilization patterns in early symptomatic AD prior to enrollment into Phase 2/3 clinical trial AMARANTH. Alzheimers Dement 2021. [DOI: 10.1002/alz.051019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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5
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Chandler J, Rentz DM, Zagar A, Kim Y, Zimmer JA, Schwartz RL, Fillit H. Disease progression and costs at 3‐year follow‐up of GERAS‐US: A 3‐year study of mild cognitive impairment and mild dementia due to Alzheimer’s disease in the United States. Alzheimers Dement 2021. [DOI: 10.1002/alz.057473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Dorene M Rentz
- Harvard Medical School Boston MA USA
- Massachusetts General Hospital, Harvard Medical School Boston MA USA
- Brigham and Women's Hospital, Harvard Medical School Boston MA USA
| | | | - Yongin Kim
- Eli Lilly and Company Indianapolis IN USA
| | | | | | - Howard Fillit
- The Icahn School of Medicine at Mount Sinai New York NY USA
- Alzheimer’s Drug Discovery Foundation New York NY USA
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6
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Chandler J, Zimmer JA, Kubisiak E, Kubisiak J. Healthcare costs incurred by patients before entering GERAS‐US, a prospective, observational study of early Alzheimer’s disease: Impact of disease severity and amyloid status. Alzheimers Dement 2021. [DOI: 10.1002/alz.057253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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7
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Lu M, Pontecorvo MJ, Devous MD, Arora AK, Galante N, McGeehan A, Devadanam C, Salloway SP, Doraiswamy PM, Curtis C, Truocchio SP, Flitter M, Locascio T, Devine M, Zimmer JA, Fleisher AS, Mintun MA. Aggregated Tau Measured by Visual Interpretation of Flortaucipir Positron Emission Tomography and the Associated Risk of Clinical Progression of Mild Cognitive Impairment and Alzheimer Disease: Results From 2 Phase III Clinical Trials. JAMA Neurol 2021; 78:445-453. [PMID: 33587110 PMCID: PMC7885097 DOI: 10.1001/jamaneurol.2020.5505] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Questions What is the association between flortaucipir positron emission tomography (PET) imaging
visual classification using a clinically applicable and US Food and Drug
Administration–approved method and 18-month cognitive and functional decline in
patients with clinically diagnosed mild cognitive impairment and dementia owing to
Alzheimer disease (AD)? Findings In this analysis of 2 open-label clinical trials, visual read of an advanced
flortaucipir PET AD pattern was associated with an increased risk of 18-month cognitive
and functional decline compared with other scan patterns. Meaning Clinically applicable visual reads of flortaucipir PET scans may provide valuable
information regarding the risk of near-term clinical deterioration among patients with
clinically diagnosed mild cognitive impairment or dementia owing to AD. Importance Flortaucipir positron emission tomography (PET) scans, rated with a novel, US Food and
Drug Administration–approved, clinically applicable visual interpretation method,
provide valuable information regarding near-term clinical progression of patients with
Alzheimer disease (AD) or mild cognitive impairment (MCI). Objective To evaluate the association between flortaucipir PET visual interpretation and
patients’ near-term clinical progression. Design/Setting/Participants Two prospective, open-label, longitudinal studies were conducted from December 2014 to
September 2019. Study 1 screened 298 patients and enrolled 160 participants who had a
flortaucipir scan at baseline visit. Study 2 selected 205 participants from the AMARANTH
trial, which was terminated after futility analysis. Out of the 2218 AMARANTH
participants, 424 had a flortaucipir scan around randomization, but 219 did not complete
18-month clinical dementia rating (CDR) assessments and thus were excluded. In both
studies, all participants were diagnosed as clinically impaired, and they were
longitudinally followed up for approximately 18 months after baseline. Main Outcomes and Measures Flortaucipir scans were rated as either advanced or nonadvanced AD pattern using a
predetermined visual interpretation method. The CDR sum of box (CDR-SB) score was used
as primary clinical end point measurement in both studies. Results Of the 364 study participants who had readable scans, 48% were female
(n = 174 of 364), and the mean (SD) age was 71.8 (8.7) years. Two hundred
forty participants were rated as having an advanced AD pattern. At 18 months follow-up,
70% of those with an advanced AD pattern (n = 147 of 210) had 1 point or
more increase in CDR-SB, an event predefined as clinically meaningful deterioration. In
contrast, only 46% of those with a nonadvanced AD pattern scan (n = 48 of
105) experienced the same event (risk ratio [RR], 1.40; 95% CI, 1.11-1.76;
P = .005). The adjusted mean CDR-SB changes were 2.28 and
0.98 for advanced and nonadvanced AD pattern groups, respectively
(P < .001). Analyses with other clinical end point
assessments, as well as analyses with each individual study’s data, consistently
indicated a higher risk of clinical deterioration associated with an advanced AD scan
pattern. Conclusions and Relevance These results suggest that flortaucipir PET scans, when interpreted with an US Food and
Drug Administration–approved, clinically applicable visual interpretation method,
may provide valuable information regarding the risk of clinical deterioration over 18
months among patients with AD and MCI. Trial Registration ClinicalTrials.gov Identifier: NCT02016560
and NCT03901105
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Affiliation(s)
- Ming Lu
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Michael J Pontecorvo
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Michael D Devous
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Anupa K Arora
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Nicholas Galante
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Anne McGeehan
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Catherine Devadanam
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Stephen P Salloway
- Butler Hospital, Providence, Rhode Island.,Brown University, Providence, Rhode Island
| | - P Murali Doraiswamy
- Duke University School of Medicine and the Duke Institute of Brian Science Center, Durham, North Carolina
| | | | - Stephen P Truocchio
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Matthew Flitter
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Tricia Locascio
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | - Marybeth Devine
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania
| | | | | | - Mark A Mintun
- Avid Radiopharmaceuticals, A Wholly Owned Subsidiary of Eli Lilly and Co, Philadelphia, Pennsylvania.,Eli Lilly and Company, Indianapolis, Indiana
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Zimmer JA, Shcherbinin S, Devous MD, Bragg SM, Selzler KJ, Wessels AM, Shering C, Mullen J, Landry J, Andersen SW, Downing AM, Fleisher AS, Svaldi DO, Sims JR. Lanabecestat: Neuroimaging results in early symptomatic Alzheimer's disease. Alzheimers Dement (N Y) 2021; 7:e12123. [PMID: 33614894 PMCID: PMC7882543 DOI: 10.1002/trc2.12123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Lanabecestat, a beta-site amyloid precursor protein-cleaving enzyme 1 (BACE1) inhibitor, was investigated as a potential Alzheimer's disease (AD)-modifying treatment. As previously reported, amyloid beta (Aβ) neuritic plaque burden reduction did not result in clinical benefit. Lanabecestat's effects on neuroimaging biomarkers and correlations between neuroimaging biomarkers and efficacy measures are reported. METHODS AMARANTH and DAYBREAK-ALZ were 104- and 78-week, multicenter, randomized, double-blind, placebo-controlled studies of lanabecestat in early symptomatic AD (AMARANTH) and mild AD dementia (DAYBREAK-ALZ). Patients randomly (1:1:1) received placebo, lanabecestat 20 mg, or lanabecestat 50 mg daily (AMARANTH, n = 2218; DAYBREAK-ALZ, n = 1722). Florbetapir positron emission tomography (PET), fluorodeoxyglucose (FDG) PET, flortaucipir PET, and volumetric magnetic resonance imaging (MRI) were used to measure Aβ neuritic plaque burden, cerebral metabolism, aggregated tau neurofibrillary tangles, and brain volume, respectively. Additionally, florbetapir perfusion scans were performed in DAYBREAK-ALZ. Efficacy measures included 13-item Alzheimer's Disease Assessment Scale-Cognitive Subscale, Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory, Clinical Dementia Rating-Sum of Boxes, Functional Activities Questionnaire, and Mini-Mental State Examination. These studies stopped early due to futility. RESULTS Despite previously observed annualized reduction in Aβ neuritic plaque burden, there were no treatment differences in annualized change of aggregated tau neurofibrillary tangle burden (AMARANTH, n = 284; DAYBREAK-ALZ, n = 70), cerebral metabolism (AMARANTH, n = 260; DAYBREAK-ALZ, n = 38) and perfusion (DAYBREAK-ALZ, n = 213). Greater brain volume reduction (AMARANTH, n = 1697 [whole brain]; DAYBREAK-ALZ, n = 650 [whole brain]) occurred on lanabecestat compared to placebo. Higher baseline aggregated tau neurofibrillary tangle burden, lower cerebral metabolism, and lower brain volumes correlated with poorer baseline efficacy scores and greater clinical worsening. Lower baseline cerebral perfusion correlated with poorer baseline efficacy scores. Reduction in cerebral metabolism or whole brain volume correlated with clinical worsening, regardless of treatment assignment. DISCUSSION Tau pathology and cerebral metabolism assessments showed no evidence of lanabecestat slowing pathophysiologic progression of AD. Lanabecestat exposure was associated with brain volume reductions. Correlations between imaging measures and cognitive assessments may aid future study design.
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Affiliation(s)
| | | | | | | | | | | | - Craig Shering
- AstraZeneca, NeuroscienceBiopharmaceuticals R&DBostonMassachusettsUSA
| | - Jamie Mullen
- AstraZeneca, NeuroscienceBiopharmaceuticals R&DBostonMassachusettsUSA
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9
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Zimmer JA, Andersen SW, Wessels AM, Shering C, Sims JR. Reasons for study exclusion by sex in lanabecestat studies AMARANTH and DAYBREAK‐ALZ. Alzheimers Dement 2020. [DOI: 10.1002/alz.038663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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10
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Chandler J, Zagar A, Kim Y, Zimmer JA, Rentz DM, Schwartz RL, Fillit HM. Disease progression and costs at two‐year follow‐up of GERAS‐US: A three‐year study of mild cognitive impairment and mild dementia due to Alzheimer’s disease in the United States. Alzheimers Dement 2020. [DOI: 10.1002/alz.038768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | | | - Yongin Kim
- Eli Lilly and Company Indianapolis IN USA
| | | | - Dorene M Rentz
- Massachusetts General Hospital Harvard Medical School Boston MA USA
| | | | - Howard M Fillit
- Geriatric Medicine, Palliative Care and Neuroscience The Icahn School of Medicine at Mount Sinai New York NY USA
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11
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Wessels AM, Tariot PN, Zimmer JA, Selzler KJ, Bragg SM, Andersen SW, Landry J, Krull JH, Downing AM, Willis BA, Shcherbinin S, Mullen J, Barker P, Schumi J, Shering C, Matthews BR, Stern RA, Vellas B, Cohen S, MacSweeney E, Boada M, Sims JR. Efficacy and Safety of Lanabecestat for Treatment of Early and Mild Alzheimer Disease: The AMARANTH and DAYBREAK-ALZ Randomized Clinical Trials. JAMA Neurol 2020; 77:199-209. [PMID: 31764959 PMCID: PMC6902191 DOI: 10.1001/jamaneurol.2019.3988] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Alzheimer disease (AD) is a neurodegenerative disorder characterized by cognitive deterioration and impaired activities of daily living. Current treatments provide only minor symptomatic improvements with limited benefit duration. Lanabecestat, a brain-permeable inhibitor of human beta-site amyloid precursor protein-cleaving enzyme 1 (BACE1/β-secretase), was developed to modify the clinical course of AD by slowing disease progression. Objective To assess whether lanabecestat slows the progression of AD compared with placebo in patients with early AD (mild cognitive impairment) and mild AD dementia. Design, Setting, and Participants AMARANTH (first patient visit on September 30, 2014; last patient visit on October 4, 2018) and DAYBREAK-ALZ (first patient visit on July 1, 2016; last patient visit on September 28, 2018) were randomized, placebo-controlled, phase 2/3 and phase 3 clinical trials lasting 104 weeks and 78 weeks, respectively. AMARANTH and DAYBREAK-ALZ were multicenter, global, double-blind studies conducted at 257 and 251 centers, respectively, located in 15 and 18 countries or territories, respectively. A population-based sample of men and women aged 55 to 85 years who met National Institute on Aging-Alzheimer's Association criteria for early AD or mild AD dementia was screened using cognitive assessments, and the presence of amyloid was confirmed. Patients were excluded for unstable medical conditions or medication use, significant cerebrovascular pathologic findings, or a history of vitiligo and/or current evidence of postinflammatory hypopigmentation. AMARANTH screened 6871 patients; 2218 (32.3%) were randomized, and 539 patients completed the study. DAYBREAK-ALZ screened 5706 patients; 1722 (30.2%) were randomized, and 76 patients completed the study. Interventions Patients were randomized (1:1:1) to once-daily oral doses of lanabecestat (20 mg), lanabecestat (50 mg), or placebo. Main Outcomes and Measures The primary outcome measure was change from baseline on the 13-item Alzheimer Disease Assessment Scale-cognitive subscale. Secondary outcomes included Alzheimer's Disease Cooperative Study-Instrumental Activities of Daily Living Inventory, Clinical Dementia Rating, Functional Activities Questionnaire, Mini-Mental State Examination, and Neuropsychiatric Inventory. Efficacy analyses were conducted on the intent-to-treat population. Results Among 2218 AMARANTH patients, the mean (SD) age was 71.3 (7.1) years, and 1177 of 2218 (53.1%) were women. Among 1722 DAYBREAK-ALZ patients, the mean (SD) age was 72.3 (7.0) years, and 1023 of 1722 (59.4%) were women. Both studies were terminated early after futility analysis. There were no consistent, reproducible dose-related findings on primary or secondary efficacy measures. Psychiatric adverse events, weight loss, and hair color changes were reported in a higher percentage of patients receiving lanabecestat than placebo. Conclusions and Relevance Treatment with lanabecestat was well tolerated and did not slow cognitive or functional decline. Trial Registration ClinicalTrials.gov identifiers: NCT02245737 and NCT02783573.
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Affiliation(s)
| | - Pierre N Tariot
- Banner Alzheimer's Institute, University of Arizona College of Medicine, Phoenix
| | | | | | | | | | - John Landry
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | | | | | - Jamie Mullen
- AstraZeneca, Waltham, Massachusetts, and Gaithersburg, Maryland.,Now retired
| | - Peter Barker
- AstraZeneca, Waltham, Massachusetts, and Gaithersburg, Maryland
| | - Jennifer Schumi
- AstraZeneca, Waltham, Massachusetts, and Gaithersburg, Maryland
| | - Craig Shering
- AstraZeneca, Waltham, Massachusetts, and Gaithersburg, Maryland
| | | | - Robert A Stern
- Alzheimer's Disease Center, Boston University School of Medicine, Boston, Massachusetts
| | - Bruno Vellas
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Unités Mixtes de Recherche Institut National de la Santé et de la Recherche Médicale 1027, Université Toulouse III-Paul Sabatier, Toulouse, France
| | - Sharon Cohen
- Toronto Memory Program, Toronto, Ontario, Canada
| | | | - Mercè Boada
- Research Center and Memory Clinic, Fundació Alzheimer Centre Educacional, Institut Català de Neurociències Aplicades, Barcelona-Universitat Internacional de Catalunya, Barcelona, Spain.,Networking Research Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - John R Sims
- Eli Lilly and Company, Indianapolis, Indiana
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12
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Monk SA, Kugler AR, Andersen SW, Ayan-Oshodi MA, James DE, Mullen J, Zimmer JA, Willis BA. Clinically Negligible Pharmacokinetic and Pharmacodynamic Interactions Between Lanabecestat and Dabigatran Etexilate, a Prototypical P-gp Substrate. J Clin Pharmacol 2019; 60:586-594. [PMID: 31853995 DOI: 10.1002/jcph.1558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 10/25/2019] [Indexed: 11/10/2022]
Abstract
Lanabecestat, a novel β-site amyloid precursor protein-cleaving enzyme 1 inhibitor evaluated for Alzheimer treatment, inhibits P-glycoprotein (P-gp) activity in vitro. After oral 50-mg lanabecestat administration, gastric fluid lanabecestat concentrations exceed half-maximal inhibitory concentration (IC50 ), suggesting P-gp inhibition at the intestinal wall. Plasma drug concentrations following 50 mg lanabecestat administered once daily are <10% of IC50 , suggesting minimal systemic P-gp interaction. Dabigatran etexilate (DE) is the prodrug of dabigatran, a thrombin inhibitor and P-gp substrate, making dabigatran exposure an intestinal P-gp activity indicator. This study (NCT02568397) was conducted in 60 healthy subjects receiving a single dose of 150 mg DE alone or during a lanabecestat treatment regimen. On day 16, lanabecestat and DE were coadministered; on day 20, DE was dosed 4 hours after lanabecestat. Safety was assessed using clinical labs, electrocardiogram, vital signs, Columbia Suicide Severity Rating Scale scores, adverse events, and eye and skin examinations. Pharmacokinetic/pharmacodynamic samples were collected up to 36 hours postdose. Geometric mean plasma dabigatran area under the curve from time 0 to infinity (AUC0-∞ ) and the maximum plasma drug concentration (Cmax ) increased by 15% and 17%, respectively, when coadministered with lanabecestat. When DE was dosed 4 hours after lanabecestat, there was no effect on plasma dabigatran AUC0-∞ , Cmax , or thrombin time. DE had no effect on lanabecestat's AUC0-∞ and Cmax at steady state (day 16) versus lanabecestat alone (day 15). No clinically relevant safety concerns were observed. Lanabecestat has no clinically meaningful effect on dabigatran exposure or on P-gp activity at the intestinal wall.
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13
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Downing AM, Wessels AM, Zimmer JA, Nickell L, Monroe K, Andersen SW, Mullen J, Sims JR. P4‐210: LANABECESTAT: SCREENING PERFORMANCE FROM THE AMARANTH STUDY. Alzheimers Dement 2018. [DOI: 10.1016/j.jalz.2018.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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14
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Sims JR, Downing AM, Andersen SW, Wessels AM, Zimmer JA, Mullen J, Schumi J, Stern RA, Vellas B, Boada M, Cohen S, MacSweeney E, Tariot PN. DT‐01‐04: LANABECESTAT: BASELINE CHARACTERISTICS OF PARTICIPANTS RANDOMIZED IN THE PHASE 2/3 AMARANTH STUDY. Alzheimers Dement 2018. [DOI: 10.1016/j.jalz.2018.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mercè Boada
- Fundació ACE. Barcelona Alzheimer Treatment and Research CenterBarcelonaSpain
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Willis BA, Lowe SL, Daugherty LL, Dean RA, English B, Ereshefsky L, Gevorkyan H, James DE, Jhee S, Lin Q, Lo A, Mergott DJ, Monk SA, Nakano M, Zimmer JA, Irizarry MC. P1‐044: Pharmacokinetics, Pharmacodynamics, Safety, and Tolerability of LY3202626, a Novel Bace1 Inhibitor, in Healthy Subjects and Patients with Alzheimer’s Disease. Alzheimers Dement 2016. [DOI: 10.1016/j.jalz.2016.06.791] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | | | | | | | - Hakop Gevorkyan
- California Clinical Trials Medical Group, Inc.GlendaleCA USA
| | | | | | - Qun Lin
- Eli Lilly and CompanyIndianapolisIN USA
| | - Albert Lo
- Eli Lilly and CompanyIndianapolisIN USA
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16
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Organiscak JA, Cecala AB, Zimmer JA, Holen B, Baregi JR. Air cleaning performance of a new environmentally controlled primary crusher operator booth. ACTA ACUST UNITED AC 2016; 68:31-37. [PMID: 26937052 DOI: 10.19150/me.6469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The National Institute for Occupational Safety and Health (NIOSH) cooperated with 3M Company in the design and testing of a new environmentally controlled primary crusher operator booth at the company's Wausau granite quarry near Wausau, WI. This quarry had an older crusher booth without a central heating, ventilation and air conditioning (HVAC) system, and without an air filtration and pressurization system. A new replacement operator booth was designed and installed by 3M based on design considerations from past NIOSH research on enclosed cab filtration systems. NIOSH conducted pre-testing of the old booth and post-testing of the new booth to assess the new filtration and pressurization system's effectiveness in controlling airborne dusts and particulates. The booth's dust and particulate control effectiveness is described by its protection factor, expressed as a ratio of the outside to inside concentrations measured during testing. Results indicate that the old booth provided negligible airborne respirable dust protection and low particulate protection from the outside environment. The newly installed booth provided average respirable dust protection factors from 2 to 25 over five shifts of dust sampling with occasional worker ingress and egress from the booth, allowing some unfiltered contaminants to enter the enclosure. Shorter-term particle count testing outside and inside the booth under near-steady-state conditions, with no workers entering or exiting the booth, resulted in protection factors from 35 to 127 on 0.3- to 1.0-μm respirable size particulates under various HVAC airflow operating conditions.
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Affiliation(s)
- J A Organiscak
- National Institute for Occupational Safety and Health, Office of Mine Safety and Health Research, Pittsburgh, PA, USA
| | - A B Cecala
- National Institute for Occupational Safety and Health, Office of Mine Safety and Health Research, Pittsburgh, PA, USA
| | - J A Zimmer
- National Institute for Occupational Safety and Health, Office of Mine Safety and Health Research, Pittsburgh, PA, USA
| | - B Holen
- 3M Company, Industrial Mineral Products Division, St. Paul, MN, USA
| | - J R Baregi
- 3M Company, Industrial Mineral Products Division, Wausau, WI, USA
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Abstract
A previously healthy 14-year-old boy collapsed after a football game, with aphasia and right hemiparesis. Cranial magnetic resonance imaging and magnetic resonance angiography revealed left middle cerebral artery distribution ischemic infarct with thrombus and possible dissection at the horizontal segment of the middle cerebral artery. The patient was treated 9 hours after collapse with intra-arterial tissue plasminogen activator, but without success. The Merci clot retrieval device was then used, but the device broke in the middle cerebral artery and led to complete occlusion. At follow-up 3 months later, the boy had persistent aphasia, but notable improvement in his right hemiparesis. This is a novel report of a complication of mechanical clot retrieval treatment in a child. Further research is needed to determine the safety and effectiveness of intracranial endovascular clot retrieval devices in children.
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Affiliation(s)
- Marcia V Felker
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana 46202, USA
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Zimmer JA, Garg BP, O'Neill DP, Golomb MR. Teaching neuroImage: MRI visualization of papilledema associated with cerebral sinovenous thrombosis in a child. Neurology 2008; 71:e12-3. [PMID: 18695153 DOI: 10.1212/01.wnl.0000325016.18727.1f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Jennifer A Zimmer
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine,Indianapolis, IN46202, USA
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Zimmer JA, Garg BP, Williams LS, Golomb MR. Age-related variation in presenting signs of childhood arterial ischemic stroke. Pediatr Neurol 2007; 37:171-5. [PMID: 17765804 DOI: 10.1016/j.pediatrneurol.2007.05.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Revised: 12/20/2006] [Accepted: 05/25/2007] [Indexed: 11/30/2022]
Abstract
The objective of this study was to determine whether there are age-related variations in the clinical presentation of cerebral arterial ischemic stroke in children after the perinatal period. We performed a retrospective record review of 76 children with cerebral arterial ischemic stroke occurring between 44 weeks of conceptional age and age 19 years. These children were seen by our pediatric stroke group between September 1, 1989 and August 1, 2005. We examined the following clinical presentations: epileptic seizures, focal weakness, and altered mental status. We compared the frequency of each presentation in children with arterial ischemic stroke up to and after age 1 year. Children aged <1 year were significantly more likely than older children to present with epileptic seizures (45.5% vs 10.8%, P = 0.01) and altered mental status (36.4% vs 7.7%, P = 0.02), and there was a trend for them to be less likely than older children to present with focal weakness (45.5% vs 76.9%, P = 0.06). Children aged <1 year with cerebral arterial ischemic stroke were more likely to present with epileptic seizures and altered mental status than children aged >or=1 year, and may be less likely to present with focal weakness. These findings may aid in the recognition of stroke in young children.
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Affiliation(s)
- Jennifer A Zimmer
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Sokol DK, Chen D, Farlow MR, Dunn DW, Maloney B, Zimmer JA, Lahiri DK. High levels of Alzheimer beta-amyloid precursor protein (APP) in children with severely autistic behavior and aggression. J Child Neurol 2006; 21:444-9. [PMID: 16948926 DOI: 10.1177/08830738060210062201] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Autism is characterized by restricted, repetitive behaviors and impairment in socialization and communication. Although no neuropathologic substrate underlying autism has been found, the findings of brain overgrowth via neuroimaging studies and increased levels of brain-derived neurotrophic factor (BDNF) in neuropathologic and blood studies favor an anabolic state. We examined acetylcholinesterase, plasma neuronal proteins, secreted beta-amyloid precursor protein (APP), and amyloid-beta 40 and amyloid-beta 42 peptides in children with and without autism. Children with severe autism and aggression expressed secreted beta-amyloid precursor protein at two or more times the levels of children without autism and up to four times more than children with mild autism. There was a trend for children with autism to show higher levels of secreted beta-amyloid precursor protein and nonamyloidogenic secreted beta-amyloid precursor protein and lower levels of amyloid-beta 40 compared with controls. This favors an increased alpha-secretase pathway in autism (anabolic), opposite to what is seen in Alzheimer disease. Additionally, a complex relationship between age, acetylcholinesterase, and plasma neuronal markers was found.
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Affiliation(s)
- Deborah K Sokol
- Department of Neurology, Indiana University School of Medicine, 702 Barnhill Drive, Indianapolis, IN 46202, USA.
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Lipton JM, Glyn JR, Zimmer JA. ACTH and alpha-melanotropin in central temperature control. Fed Proc 1981; 40:2760-4. [PMID: 6271599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Adrenocorticotropin (ACTH) and alpha-melanotropin (alpha-MSH) occur in brain tissue known to be important to temperature control. These peptides cause hypothermia if they are injected centrally in sufficient doses, but they do not act on the central set point of temperature control. Instead they appear to inhibit central pathways for heat conservation and production. In addition to their hypothermic capability, these peptides are antipyretic when given centrally in doses that have no effect on normal body temperature. ACTH has previously been associated with fever reduction in both clinical and experimental studies, and it may be that endogenous central ACTH is important for limitation of maximal fever. The hypothermic and antipyretic effects of ACTH do not depend on stimulation of the adrenal cortex because they are also observed in adrenalectomized rabbits. Nor is the antipyretic effect limited to the rabbit inasmuch as a comparable effect has been demonstrated in the squirrel monkey. The two peptides may be involved in central mediation of normal thermoregulation and fever, perhaps limiting the febrile response and other rises in body temperature by acting as neurotransmitters or neuromodulators in central thermoregulatory pathways.
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Abstract
Central administration of ACTH (1-24) reduces fever in normal rabbits in doses that have no effect on afebrile body temperature. Previous experimental and clinical reports indicate that peripheral administration of both ACTH and corticosteroids reduces fever, and since central injection of corticosteroids can also lower fever it might be that the antipyretic effect of intracerebroventricular (ICV) ACTH (1-24) is due to adrenal stimulation. To learn whether this endogenous central peptide can produce antipyresis independently, ACTH (1-24) was injected ICV in bilaterally adrenalectomized (ADX) rabbits made febrile by IV injections of leukocytic pyrogen (LP). ACTH (250 ng) given ICV reduced fever in these animals and had a slight hypothermic effect when given to the same rabbits when they were afebrile. Doses of 25-75 ng reduced fever without influencing normal body temperature. Intravenous injections of ACTH (2.5 micrograms) also lowered fever caused by IV LP in ADX rabbits. The present findings raise the possibility that release of endogenous central ACTH, and perhaps entry into the brain of circulating ACTH, the release of which is known to increase in fever, limits the magnitude of the febrile response by influencing central temperature controls.
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Abstract
The recent demonstration of the ability of centrally administered alpha-MSH to reduce pyrogen-induced fever in rabbits suggested a role for the peptide in central temperature control. Using a sensitive radioimmunoassay we have established the presence of immunoreactive alpha-MSH (ir alpha-MSH) in discrete CNS sites of the rabbit and have demonstrated a distribution of this activity similar to that seen in other species. Pyrogen-induced fever did not alter concentrations of ir alpha-MSH in tissue extracted from the paraventricular region of the hypothalamus, median eminence, midbrain central grey, preoptic/anterior hypothalamic region, pineal or pituitary. A decrease in arcuate nucleus ir alpha-MSH content was seen in febrile animals, although this change was not statistically significant. Significantly higher levels of ir alpha-MSH were detected in septal extracts of febrile rabbits (0.81/+-0.10 pg/micrograms protein, n=9) than in extracts from afebrile controls (0.54/+-0.04, n=17). This finding suggests the septum to be the central site of action of alpha-MSH to inhibit fever and further implies a modulatory role of the peptide in the central control of thermoregulation.
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Abstract
1. Since prostaglandins appear to mediate adrenergically stimulated renin release, the effect of indomethacin was examined on insulin-induced renin and catecholamine release in conscious rats. Insulin (10 units/kg subcutaneously) increased plasma renin activity from 2.8 +/- 0.5 to 9.0 +/- 1.1 pmol h-1 ml-1 (P less than 0.001) while also increasing plasma adrenaline, noradrenaline and the urinary excretion of prostaglandin E2 and F2 alpha. Plasma potassium and glucose were reduced by 16 and 54% respectively. 2. Indomethacin (14 mumol/kg subcutaneously) reduced the urinary excretion of prostaglandin E2 and F2 alpha by 67 and 54% respectively, without altering the other parameters. 3. Indomethacin inhibited insulin-induced renin release by 67% (P less than 0.02) and blocked the insulin-induced increases in urinary prostaglandin E2 and F2 alpha. The insulin-induced changes in plasma catecholamines, potassium and glucose were unaltered by indomethacin. 4. These findings suggest that renal prostaglandins mediate this form of adrenergically stimulated renin release by acting at a side distal to the beta-adrenoreceptor.
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