Lawrence Friedhoff

A 24-week, double-blind, placebo-controlled trial of donepezil in patients with Alzheimer's disease

The efficacy and safety of donepezil as a treatment for patients with mild to moderate Alzheimers disease (AD) was investigated in a multicenter, double-blind study. Patients were randomly assigned to treatment with placebo(n = 162), 5 mg/d donepezil (n = 154), or 10 mg/d donepezil (n = 157) for 24 weeks followed by a 6-week, single-blind placebo washout. The primary efficacy measures were the cognitive portion of the Alzheimers Disease Assessment Scale (ADAS-cog) and the Clinicians Interview Based Assessment of Change-Plus (CIBIC plus), with the Mini-Mental State Examination (MMSE), Clinical Dementia Rating Scale-Sum of the Boxes (CDR-SB), and patient rated Quality of Life (QoL) used as secondary measures. Cognitive function, as measured by the ADAS-cog, was significantly improved in the 5- and 10-mg/d donepezil groups as compared with the placebo group at weeks 12, 18, and 24. Clinicians global ratings on the CIBIC plus also improved in both the 5- and 10-mg/d donepezil groups relative to placebo. At the end of the 6-week placebo washout phase, ADAS-cog scores and CIBIC plus ratings were not significantly different for the three groups. Significant treatment benefits were also observed consistently in both the 5- and 10-mg/d groups on the MMSE and the CDR-SB, but there was no consistent effect on the patient-rated QoL. Cholinergic side effects (primarily diarrhea, nausea, and vomiting) were reported more often in the 10-mg/d group than either the 5-mg/d or placebo groups. Side effects were transient and generally mild in severity. These data indicate that donepezil is a well-tolerated drug that improves cognition and global function in patients with mild to moderate AD.

The efficacy of RVT-101, a 5-ht6 receptor antagonist, as an adjunct to donepezil in adults with mild-to-moderate Alzheimer’s disease: Completer analysis of a phase 2b study

Paulo Fontoura, Luca Santarelli, F. Hoffmann-La Roche Ltd, Basel, Switzerland; F. Hoffmann-La Roche, Ltd., Basel, Switzerland; VU University Medical Center, Amsterdam, Netherlands; Fundacio ACE, Barcelona, Spain; Hôpital La Salpêtri ere, Paris, France; Formerly of F. Hoffmann-La Roche Ltd, Basel, Switzerland; Roche Products Limited, Welwyn Garden City, United Kingdom; Roche Products Ltd, Welwyn Garden City, United Kingdom. Contact e-mail: Robert.lasser.rl1@roche. com

A lipid A analog, E5531, blocks the endotoxin response in human volunteers with experimental endotoxemia.

BackgroundEndotoxin (lipopolysaccharide [LPS]) has been associated with sepsis and the high mortality rate seen in septic shock. The administration of a small amount of LPS to healthy subjects produces a mild syndrome qualitatively similar to that seen in clinical sepsis. We used this model to test the efficacy of an endotoxin antagonist, E5531, in blocking this LPS-induced syndrome. MethodsIn a placebo-controlled, double-blind study, we randomly assigned 32 healthy volunteers to four sequential groups (100, 250, 500, or 1000 &mgr;g of E5531). Each group of eight subjects (six assigned to E5531, two assigned to placebo) received a 30-min intravenous infusion of study drug. LPS (4 ng/kg) was administered to all subjects as an intravenous bolus in the contralateral arm at the midpoint of the infusion. Symptoms, signs, laboratory values, and hemodynamics (by echocardiogram) were evaluated at prospectively defined times. ResultsIn subjects receiving placebo, LPS caused headache, nausea, chills, and myalgias. E5531 led to a dose-dependent decrease in these symptoms that was statistically significant (p < .05) except for myalgias. The signs of endotoxemia (fever, tachycardia, and hypotension) were consistently inhibited at the three higher doses (250, 500, and 1000 &mgr;g, p < .05). Tumor necrosis factor-&agr; and interleukin-6 blood levels were both lower in those who received E5531 (p < .0001). The C-reactive protein level and white blood cell count response were decreased at all doses (p < .0001). The hyperdynamic cardiovascular state (high cardiac index and low systemic vascular resistance) associated with endotoxin challenge was significantly inhibited at the higher doses of E5531. ConclusionsE5531 blocks the symptoms and signs and cytokine, white blood cell count, C-reactive protein, and cardiovascular response seen in experimental endotoxemia. This agent is a potent inhibitor of endotoxin challenge in humans and may be of benefit in the prevention or treatment of sepsis and septic shock.

Phenserine Efficacy in Alzheimer's Disease

To gather preliminary evidence in Alzheimers disease (AD) for the efficacy of phenserine, a non-competitive acetylcholinesterase inhibitor that has independent modulatory effects on amyloid-β generation, a 12-week comparison of patients receiving phenserine (10 and 15 mg BID) or placebo was conducted under double-blind conditions. Patients who completed 12 weeks of the double-blind before others were continued in the double-blind to determine longer-term treatment effects. At 12 weeks, mean ADAS-cog (AD assessment scale-cognitive) changes from baseline were -2.5 and -1.9 for high-dose phenserine (n=83) and placebo (n=81) groups, respectively, a non-statistically significant improvement for the high-dose phenserine group relative to placebo. CIBIC+ (clinicians interview based impression of change + caregivers input) values for the high-dose and placebo groups were similar at 12 weeks. For patients who received more than 12 weeks of therapy, the ADAS-cog changes were -3.18 and -0.66 for the high-dose phenserine (n=52) and placebo (n=63) groups, respectively, a difference achieving statistical significance (p=0.0286). After 12 weeks, CIBIC+ values were 3.59 and 3.95 for the high-dose (n=54) and placebo (n=66) groups respectively (p=0.0568). These results from this short-term study are consistent with phenserine potentially benefiting mild to moderate Alzheimers disease symptomatically but do not address possible amyloid metabolic mediated effects on disease processes in AD.

TRANSLATING BENCH RESEARCH INTO EVOLVING DRUG DEVELOPMENT: THE CASE STUDY OF 5HT6 ANTAGONISTS

determined by LC-MS/MS. Results:CSF Cytokines: majority were below-level-of-quantitation. CSF-IL8 was only cytokine quantifiable at all time-points. CSF-TNFa was quantifiable in approximately one-third of samples. Peak CSF-IL8 at EOT was significantly and inversely correlated (p1⁄40.008; r1⁄4.79)to plasma drug-exposure (AUC0-12); similar trend seen for CSF-TNFa (p1⁄40.08; r1⁄4.48). For both, reduction in levels was prominent at average plasma drug-concentration (CAVERAGE) >10 ng/mL, the target concentration for anti-inflammatory activity based on preclinical studies. CSF-Ab: Percent change in mean levels over 24hours was significantly correlated to AUC0-12 for each of CSF Ab38 (p1⁄40.03; r1⁄40.62), Ab40 (p1⁄40.012; r1⁄40.75), and Ab42 (p1⁄40.047; r1⁄40.58). For each, CSF-Ab levels were neutral or decreased at CAVERAGE < 8 ng/mL and increased at CAVERAGE > 10 ng/mL (see figure for Ab40). Conclusions:As one of the downstream effects of p38 inhibition is reduction of pro-inflammatory cytokine production, the PK-PD correlation between AUC0-12 and CSF-IL8/TNFa indicates target engagement. Further, the apparent relationship between anti-inflammatory effect and reduction in CSF amyloid beta levels at CAVERAGE > 10 ng/mL, and the known requirement of p38 MAPK for microglial-mediated uptake of amyloid-beta (Adolfsson, 2012), suggests that the increase in CSF amyloid-beta at high concentrations may be due to high-level p38 MAPK inhibition within microglia.

EVALUATION OF THE NEUROPROTECTIVE EFFECT OF INTEPIRDINE IN AN IN VITRO OXYGEN/GLUCOSE DEPRIVATION-INDUCED CYTOTOXICITY MODEL

by in-vitro dissolution, permeability study (everted intestine sac method), and in-vivo oral pharmacokinetic study using rats. Also, its safety and efficacy were evaluated after 3 months of treatment by oral administration. Results:The soluplus based NEF displayed dramatic improvement in aqueous solubility (17.53-fold) and stability due to amorphization, hydrogen bonding interaction and micellization. Moreover, the NEF demonstrated significant improvement in intestinal permeability and dissolution profile of EDR. Furthermore, the oral BA of NEF showed 10.2, 16.1 and 14.8-fold enhancement compared to EDR suspension at 46, 138 and 414 mM/kg dose. Besides, our data confirms non-toxicity up to 414 mM/kg dose after 3 months and its potential to reverse AD-like cognitive deficits of APP/PS1 mice in dose dependent manner. Conclusions:NEF has great potential to mitigate the limitation associated with EDR and can pave the way for its clinical development for the treatment of AD.

RESULTS OF A PHASE 2 STUDY OF NELOTANSERIN, A NOVEL 5HT2A RECEPTOR INVERSE AGONIST, IN LEWY BODY DEMENTIA SUBJECTS EXPERIENCING VISUAL HALLUCINATIONS

MRI-based biomarkers of regenerative efficacy.Results:Allopregnanolone at two doses, 2mg and 4mg, was intravenously infused once perweek for 12weeks to 8 participants / dose cohort (6 allopregnanolone + 2 placebo / dose cohort).Within 15minutes of start of infusion, peak plasma level was reached Cma 1⁄4 46.34 +/23 nanomolar. No sedationwas observed in any participant during or after infusion indicating a tolerable dose. The Cmax closely correlated (R1⁄40.77) with Allo delivered in mg/kg dose. Twelve-week exposure to 2mg or 4mg of Allopregnanolone once per week had no detectable adverse effects. Dose cohort 3 is underway. Primary safety outcomes and secondary exploratory outcomes of MRI based biomarkers, metabolomics, cognition and iPSC derived neural stem cell response to Allo will be presented. Conclusions: Allopregnanolone is a first in class regenerative therapeutic forMCI andAD that targets endogenous neural stem cells and disease modifying mechanisms. Trial outcomes will provide: 1) an estimated safe andwell-tolerated dose ofAllo; 2) parameter estimates for MRI based markers of regeneration, cognitive efficacy and iPSC / neural stem cell based indicator of responders and foundation to advance to a Phase 2 proof of concept trial ofAllo in persons diagnosed with early AD. Supported by NIA U01AG03111 & U01AG047222 toRDB;UF1AG046148 toRDB&LS;ADDFtoRDB

IN VIVO ALTERATIONS IN BRAIN GLUCOSE UTILIZATION WITH RVT-101, A 5HT6 INHIBITOR FOR THE TREATMENT OF ALZHEIMER’S DISEASE

neuroprotective effects in iron-overload condition. Recently a new iron chelator, deferasirox, has been used to treat patients with ironoverload condition. However, the effects of iron-overload condition with and without interventions, including iron chelators (deferoxamine, deferiprone, and deferasirox), NAC and combined therapy on brain mitochondrial function, brain mitochondrial dynamic, Alzheimer’s pathology and dendritic spine density have not yet been investigated. In the present study, we hypothesize that 1) iron overload causes BBB breakdown, brain mitochondrial dysfunction, disturbance of the brain mitochondrial dynamic, Alzheimer’s pathology and dendritic spine density reduction and 2) all interventions reverse these brain defects.Methods:Male Wistar rats (n1⁄4 42) were assigned to receive either a normal diet (ND: n1⁄46) or a high-iron diet (HFe: n1⁄436) for 4 months. At the 2 month, HFefed rats were subdivided into six subgroups (n1⁄46/subgroup). Each subgroup received either: vehicle, deferoxamine, deferiprone, deferasirox, NAC or combined deferiprone with NAC, whereas NDfed rats received a vehicle. At the end of the 4 month, rats were sacrificed and their brains were rapidly removed to determine brain iron level and deposition, brain mitochondrial function, BBB protein expression, brain mitochondrial dynamics, brain apoptosis levels, Alzheimer’s pathology and dendritic spine density. Results: Chronic high-iron diet consumption increased brain iron level with brain iron deposition (Fig 1A), and brain mitochondrial dysfunction, disturbed the brain mitochondrial dynamic, increased Alzheimer’s pathology and reduced dendritic spines density. All treatments, except deferasirox, attenuated all of these impairments. Moreover, combined therapy provided a better efficacy particularly in the dendritic spine preservation (Fig 1B). Conclusions: These findings suggested that iron overload induced brain iron toxicity and iron chelator combined with antioxidant therapy provided robust neuroprotection.

EFFECT OF FOOD ON THE PHARMACOKINETICS OF RVT-101 IN HEALTHY ADULT SUBJECTS

activates eNOS, causing production of nitric oxide (NO), which then triggers transcription of genes involved inmitochondrial biogenesis (3). Thiazolidinediones, e.g., pioglitazone, induce mitochondrial biogenesis by increasing expression of PPAR-1a-coactivator, the principle regulator of mitochondrial biogenesis. (4). Treatment using concurrent combinations having different targets is more effective than sequentially using single agents. A clinical trial would test the hypothesis that a combination of lithium, erythropoietin, and pioglitazone, might impede the progression of MCI to AD, or of early to more advanced AD. Conclusions:Dysfunctional mitochondria underlie AD and may be disposed, by combining lithium, erythropoietin, and pioglitazone to enhance mitophagy, which then stimulates production of new organelles by enhancing mitochondrial biogenesis. 1. Nixon, J Cell Sci 2007;120:4081-4091. 2. Sarkar, J Cell Biol 2011;101:514-519. 3. Burger, Cardiovasc Res 2006;72:51-59. 4. Gosh, Mol Pharmacol 2007;71:1695-1702.

A LARGE, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY EVALUATING RVT-101, A NEUROTRANSMITTER-TARGETED THERAPY, IN SUBJECTS WITH MILD-TO-MODERATE ALZHEIMER’S DISEASE ON DONEPEZIL TREATMENT: PHASE 3 MINDSET STUDY DESIGN

P4-001 A LARGE, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY EVALUATING RVT-101, A NEUROTRANSMITTER-TARGETED THERAPY, IN SUBJECTS WITH MILD-TOMODERATE ALZHEIMER’S DISEASE ON DONEPEZILTREATMENT: PHASE 3 MINDSET STUDY DESIGN Ilise Lombardo, Shari Coslett, David W. Liu, Kunal S. Kishnani, Benjamin Zimmer, Lawrence Friedhoff, Axovant Sciences, Inc., New York, NY, USA; 2 Roivant Sciences, Inc., New York, NY, USA. Contact e-mail: ilise.lombardo@axovant.com