Peter S. Whitton

Exenatide and the treatment of patients with Parkinson’s disease

UNLABELLED BACKGROUND. There is increasing interest in methods to more rapidly and cost-efficiently investigate drugs that are approved for clinical use in the treatment of another condition. Exenatide is a type 2 diabetes treatment that has been shown to have neuroprotective/neurorestorative properties in preclinical models of neurodegeneration. METHODS. As a proof of concept, using a single-blind trial design, we evaluated the progress of 45 patients with moderate Parkinsons disease (PD), randomly assigned to receive subcutaneous exenatide injection for 12 months or to act as controls. Their PD was compared after overnight withdrawal of conventional PD medication using blinded video assessment of the Movement Disorders Society Unified Parkinsons Disease Rating Scale (MDS-UPDRS), together with several nonmotor tests, at baseline, 6 months, and 12 months and after a further 2-month washout period (14 months). RESULTS. Exenatide was well tolerated, although weight loss was common and l-dopa dose failures occurred in a single patient. Single-blinded rating of the exenatide group suggested clinically relevant improvements in PD across motor and cognitive measures compared with the control group. Exenatide-treated patients had a mean improvement at 12 months on the MDS-UPDRS of 2.7 points, compared with mean decline of 2.2 points in control patients (P = 0.037). CONCLUSION. These results demonstrate a potential cost-efficient approach through which preliminary clinical data of possible biological effects are obtainable, prior to undertaking the major investment required for double-blind trials of a potential disease-modifying drug in PD. TRIAL REGISTRATION Clinicaltrials.gov NCT01174810. FUNDING Cure Parkinsons Trust.

Motor and Cognitive Advantages Persist 12 Months After Exenatide Exposure in Parkinson’s Disease

BACKGROUND Data from an open label randomised controlled trial have suggested possible advantages on both motor and non-motor measures in patients with Parkinsons disease following 12 months exposure to exenatide. OBJECTIVE Continued follow up of these same patients was performed to investigate whether these possible advantages persisted in the prolonged absence of this medication. METHODS All participants from an open label, randomised controlled trial of exenatide as a treatment for Parkinsons disease, were invited for a further follow up assessment at the UCL Institute of Neurology. This visit included all 20 individuals who had previously completed twelve months exposure to exenatide 10ug bd and the 24 individuals who had acted as randomised controls. Motor severity of PD was compared after overnight withdrawal of conventional PD medication using blinded video assessment of the MDS-UPDRS, together with several non-motor tests. This assessment was thus 24 months after their original baseline visit, i.e. 12 months after cessation of exenatide. RESULTS Compared to the control group of patients, patients previously exposed to exenatide had an advantage of 5.6 points (95% CI, 2.2-9.0; p = 0.002) using blinded video rating of the MDS-UPDRS part 3 motor subscale. There was also a difference of 5.3 points; (95% CI, 9.3-1.4; p = 0.006) between the 2 groups on the Mattis Dementia Rating scale. CONCLUSIONS While these data must still not be interpreted as evidence of neuroprotection, they nevertheless provide strong encouragement for the further study of this drug as a potential disease modifying agent in Parkinsons disease.

Regional Effects of Sodium Valproate on Extracellular Concentrations of 5-Hydroxytryptamine, Dopamine, and Their Metabolites in the Rat Brain: An In Vivo Microdialysis Study

Abstract: The effects of sodium valproate (VPA; 100, 200, and 400 mg/kg, i.p.) on ventral hippocampal and anterior caudate putamen extracellular levels ofdopamine (DA) and 5‐hydroxytryptamine (5‐HT) were examined using in vivo microdialysis. VPA induced dose‐related increases in dialysate DA, 3,4‐dihydroxyphenylacetic acid, and 5‐HT in the ventral hippocampus. Anterior caudate putamen dialysate 5‐HT was also dose dependently elevated by the drug, whereas DA levels tended to decrease with increasing VPA dose. In contrast, VPA (200, 400, and 800 mg/kg, i.p.) produced no significant elevation of DA in posterior caudate putamen dialysates, although 5‐HT levels were significantly elevated at the 400‐ and 800‐mg/kg doses. In all three regions studied, dialysate concentrations of 5‐hydroxyindoleacetic acid and homovanillic acid remained at basal levels following VPA treatments. The results are discussed with regard to the possible anticonvulsant mode of action of VPA.

Glucagon-like peptide 1 receptor stimulation as a means of neuroprotection

Glucagon‐like peptide 1 (GLP‐1) is a relatively recently discovered molecule originating in the so‐called L‐cells of the intestine. The peptide has insulinotrophic properties and it is this characteristic that has predominantly been investigated. This has led to the use of the GLP‐1‐like peptide exendin‐4 (EX‐4), which has a much longer plasma half‐life than GLP‐1 itself, being used in the treatment of type II diabetes. The mode of action of this effect appears to be a reduction in pancreatic apoptosis, an increase in beta cell proliferation or both. Thus, the effects of GLP‐1 receptor stimulation are not based upon insulin replacement but an apparent repair of the pancreas. Similar data suggest that the same effects may occur in other peripheral tissues. More recently, the roles of GLP‐1 and EX‐4 have been studied in nervous tissue. As in the periphery, both peptides appear to promote cellular growth and reduce apoptosis. In models of Alzheimers disease, Parkinsons disease and peripheral neuropathy, stimulation of the GLP‐1 receptor has proved to be highly beneficial. In the case of Parkinsons disease this effect is evident after the neurotoxic lesion is established, suggesting real potential for therapeutic use. In the present review we examine the current status of the GLP‐1 receptor and its potential as a therapeutic target.

MK-801 increases extracellular 5-hydroxytryptamine in rat hippocampus and striatum in vivo.

Abstract: The effect of MK‐801 (0.25 or 0.5 mg/kg) on the extracellular concentration of 5‐hydroxytryptamine (5‐HT) and 5‐hydroxyindoleacetic acid (5‐HIAA) in rat hippocampus and striatum was studied using intracerebral dialysis. The dialysate 5‐HT concentration was dose‐dependently increased by MK‐801 in both regions. In the hippocampus, at the higher drug dose a slow increase in the 5‐HIAA level was observed, and this became significant 3 h after treatment. In contrast to this, the extracellular 5‐HIAA content in the striatum was significantly decreased 150 min after administration of both doses of MK‐801. The data are discussed in the light of the known behavioural effects of MK‐801 and possible N‐methyl‐d‐aspartic acid receptor regulation of 5‐HT release.

Lamotrigine, carbamazepine and phenytoin differentially alter extracellular levels of 5-hydroxytryptamine, dopamine and amino acids

We have studied the effects of treatment with the anticonvulsants lamotrigine (LTG), phenytoin (PHN) and carbamazepine (CBZ) on basal and stimulated extracellular aspartate (ASP), glutamate (GLU), taurine (TAU), GABA, 5-hydroxytryptamine (5-HT) and dopamine (DA) in the hippocampus of freely moving rats using microdialysis. All of the drugs investigated have had inhibition of Na(+) channel activity implicated as their principal mechanism of action. Neither LTG (10-20 mg/kg), PHN (20-40 mg/kg) or CBZ (10-20 mg/kg) had an effect on the basal extracellular concentrations of any of the amino acids studied with the exception of glutamate, which was decreased at the highest LTG dose. However, when amino acid transmitter levels were increased with 50 microM veratridine, LTG was found to cause a dose-dependent decrease in dialysate levels of all four amino acids, with the effect being most pronounced for glutamate. In contrast, PHN decreased extracellular aspartate levels but had no effect on evoked-extracellular GLU, TAU or GABA. Somewhat unexpectedly, CBZ did not alter the stimulated increase in the excitatory amino acids, GLU and ASP, but, rather surprisingly for an antiepileptic drug, markedly decreased that of the inhibitory substances TAU and GABA. The three drugs had differing effects on basal extracellular 5-HT and DA. LTG caused a dose-dependent decrease in both, while CBZ and PHN both increased extracellular 5-HT and DA. When extracellular 5-HT and DA was evoked by veratridine LTG had no significant effect on this, while PHN but not CBZ increased stimulated extracellular 5-HT and both PHN and CBZ augmented DA. Thus, the effects of the three drugs studied seemed to depend on whether extracellular transmitter levels are evoked or basal and the particular transmitter in question. This suggests that there are marked differences in the neurochemical mechanisms of antiepileptic drug action of the three compounds studied.

The effect of sodium valproate on extracellular GABA and other amino acids in the rat ventral hippocampus: an in vivo microdialysis study

We report the effects of i.p. administration of sodium valproate (VPA) on extracellular concentrations of various amino acids in the rat ventral hippocampus studied using in vivo microdialysis, followed by HPLC with fluorometric detection. At the doses used (100, 200 and 400 mg/kg), VPA had no effect on extracellular aspartate, glutamine and taurine, whilst inducing a small, but not statistically significant increase in glutamate at 200 and 400 mg/kg. In contrast, VPA administration produced a biphasic effect on extracellular GABA levels which was dependent on the dose used. At 100 mg/kg, VPA reduced GABA concentrations by 50% when compared to basal. 200 mg/kg VPA had virtually no effect, whilst 400 mg/kg VPA raised extracellular GABA levels to 200% of basal. The results are discussed in relation to the known pharmacological and anticonvulsant actions of VPA.

Nitric oxide modulates N-methyl-D-aspartate-evoked serotonin release in the raphe nuclei and frontal cortex of the freely moving rat.

The role of nitric oxide (NO) in N-methyl-D-aspartate (NMDA)-regulated release of 5-hydroxytryptamine (5-HT) in the frontal cortex and raphe nuclei of freely moving rats has been studied using microdialysis with dual probes, one in each region of the same animal. In order to do this the selective neuronal nitric oxide synthase (nNOS) inhibitor 7-nitroindazole (7-NI; 1 mM) and the NO donor S-nitroso-N-penicillamine (SNAP; 500 microM-5 mM) were used. All drugs were infused into the raphe via the dialysis probe. NMDA showed an inverse concentration effect on 5-HT release in the raphe with 25 microM decreasing 5-HT release and 100 microM increasing release. At the same time the converse effect was seen in the frontal cortex. Co-infusion of 7-NI abolished the effect of 100 microM but not 25 microM NMDA. 7-NI given alone decreased raphe 5-HT release with a concomitant increase being seen in the frontal cortex. Low concentrations of SNAP infused into the raphe were found to decrease 5HT release locally but increase release in the frontal cortex. In contrast the highest concentration of SNAP used was found to have the opposite effect in both brain regions. These data suggest that NO plays a role in mediating both basal and NMDA-evoked changes in serotonergic transmission between the raphe and frontal cortex.

Regional effects of MK-801 on dopamine and its metabolites studied by in vivo microdialysis.

The non-competitive N-methyl-D-aspartate receptor antagonist MK-801 was observed to have regionally specific effects on the extracellular concentration of dopamine and its metabolites. In rat anterior striatum, MK-801 transiently decreased extracellular dopamine, in spite of inducing intense circling behaviour which is generally associated with an increase in this neurotransmitter. In contrast, hippocampal extracellular dopamine was increased in a dose-related manner by MK-801. The possible significance of these data is discussed in relation to some of the known behavioural actions of MK-801.

N-methyl-D-aspartate receptors modulate extracellular dopamine concentration and metabolism in rat hippocampus and striatum in vivo

The effects of infusing N-methyl-D-aspartate (NMDA), and the specific NMDA receptor antagonist D-2-amino-5-phosphono-propionic acid (D-AP5) into rat hippocampus and striatum on extracellular dopamine (DA) and its metabolites dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) were studied using intracerebral microdialysis. In striatum NMDA increased DA extracellularly in a concentration-dependent manner. Against a 10 microM concentration of NMDA the increase in striatal DA was opposed by D-AP5 (10 microM in all experiments), which when infused alone significantly reduced DA concentration. Infusion of NMDA altered DOPAC level in a complex manner, with 10 microM concentration causing a significant increase 2 h after infusion, while 100 microM NMDA caused a transient decrease in the metabolite. None of treatments altered striatal dialysate HVA. In hippocampus NMDA infusion decreased dialysate DA in a concentration-dependent manner, and the decrease caused by 10 microM NMDA was reversed by D-AP5. When given alone the antagonist was without effect. NMDA infusion elevated hippocampal dialysate DOPAC and HVA, while HVA was decreased following D-AP5 infusion. These data indicate that DA release is regionally controlled by excitatory amino acids, but in differential manner.