1. 1. James Wallace M.D. Combination therapy for the treatment and prevention of Alzheimers Disease 1 - U.S. Patent Pending #US 20140271911 A1 2 - U.S. Provisional Patent Application #US 62/143,057 Lithium + Beta-Secretase (BACE) Inhibitor 1 Memantine + Levetiracetam + Beta-Secretase (BACE) Inhibitor 2 Levetiracetam + Beta-Secretase (BACE) Inhibitor 2
2. 2. Words of Caution This presentation is for educational purposes only. Please work with a knowledgeable physician before beginning any type of supplement or medication protocol.
3. 3. According the Amyloid hypothesis, Alzheimers disease is preceded by, and in some unproven manner is initiated by, Amyloid (A). 1-3 By disrupting the cleavage of Amyloid Precursor Protein (APP), beta- secretase inhibitors can potentially reduce the generation of Amyloid (A) and reduce Amyloid (A) deposits. 4,5 Proposed Mechanism of Action for BACE Inhibition 1 - Hardy J. and Allsop D., Amyloid deposition as the central event in the aetiology of Alzheimer's disease, Trends Pharmacol. Sci., vol. 12, 1991, 383-388. 2 - Karran E. et al., "The amyloid cascade hypothesis for Alzheimers disease: an appraisal for the development of therapeutics", Nat. Rev. Drug Discov., vol. 10, 2011, 698-712.. 3 - Sperling R.A. et al., "Toward defining the preclinical stages of Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease, Alzheimers Dement., vol. 7, 2011, 280-292.. 4 - Ghosh A.K. et al., Beta-Secretase as a therapeutic target for Alzheimer's disease, Neurotherapeutics, vol. 5, 2008, 399-408. 5 - Vassar R. et al., Beta-secretase cleavage of Alzheimer's amyloid precursor protein by the transmembrane aspartic protease BACE, Science, vol. 286, 1999, 735-741.
4. 4. A coding substitution on Amyloid Precursor Protein (APP) adjacent to the beta-secretase cleavage site is associated with protection against Alzheimers disease. The A673T Substitution Jonsson T. et al., "A mutation in APP protects against Alzheimers disease and age-related cognitive decline", Nature, 2012, vol. 488, 9699.
5. 5. Long before the onset of neurodegeneration, brain regions with higher rates of activity and metabolism in young adults - overlap regions observed to have significant quantities of amyloid depositi0n in subjects with Alzheimers disease - in the default mode network (DMN). 1,2 In transgenic Tg2576 mice, higher concentrations of interstitial amyloid and higher quantities of amyloid deposition have been observed in brain regions with higher rates of activity. 3 It has been proposed that neurons with increased activity rates have higher rates of synaptic vesicle release and higher rates of synaptic amyloid release resulting in increased concentrations of interstitial amyloid. 4 In Tg2576 mice, higher concentrations of interstitial amyloid have been shown to influence amyloid deposition. 3 Does regionally specific neuronal hyperactivity influence and promote regionally specific amyloid deposition? 1 - Buckner R.L. et al.,Molecular, structural, and functional characterization of Alzheimer's disease: evidence for a relationship between default activity, amyloid, and memory, J. Neurosci., vol. 25, 2005, 7709-7717. 2 - Buckner R.L. et al., The brain's default network: anatomy, function, and relevance to disease, Ann. NY Acad. Sci., vol. 1124, 2008, 1-38. 3 - Bero A.W. et al., "Neuronal activity regulates the regional vulnerability to amyloid- deposition." Nat. Neurosci., vol. 14, 2011, 750-756. 4 - Cirrito J.R. et al., "Synaptic activity regulates interstitial fluid amyloid-beta levels in vivo.", Neuron, vol. 48, 2005, 913-922. Roselli F. and Caroni P., "From Intrinsic Firing Properties to Selective Neuronal Vulnerability in Neurodegenerative Diseases" Neuron, vol. 85, 2015, 901- 910. Busche M.A. and Konnerth A., "Neuronal hyperactivity - A key defect in Alzheimer's disease?", Bioessays, 2015, Epub ahead of print.
6. 6. Increased Neuronal Activity Increased Interstitial Amyloid Increased Amyloid Accumulations Neuronal Hyperactivity (1-4) 1 - Bero A.W. et al., "Neuronal activity regulates the regional vulnerability to amyloid- deposition." Nat. Neurosci., vol. 14, 2011, 750-756. 2 - Cirrito J.R. et al., "Synaptic activity regulates interstitial fluid amyloid-beta levels in vivo.", Neuron, vol. 48, 2005, 913-922. 3 - Roselli F. and Caroni P., "From Intrinsic Firing Properties to Selective Neuronal Vulnerability in Neurodegenerative Diseases" Neuron, vol. 85, 2015, 901-910. 4 - Busche M.A. and Konnerth A., "Neuronal hyperactivity - A key defect in Alzheimer's disease?", Bioessays, 2015, Epub ahead of print. Higher Rates of Synaptic Vesicle and Synaptic Amyloid Exocytosis
7. 7. While amyloid accumulations have been implicated as an upstream factor in AD pathology, it is important to note that some patients who develop amyloid accumulations proceed to develop AD, and some do not (or did not at the time of analysis of amyloid accumulations and cognitive functioning). * Additional neuronal mechanism(s), along with amyloidogenesis, might also influence AD pathogenesis. These putative mechanism(s) could develop synchronously or asynchronously with amyloidogenesis. A combination of risk and protective factors might influence these mechanism(s) and the impact that these mechanism(s) have on disease progression. * Sperling R.A. et al., "Toward defining the preclinical stages of Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease, Alzheimers Dement., vol. 7, 2011, 280-292. Amyloid Accumulations
8. 8. Autophagy mediated extrusion of amyloid (which has been shown to be less impaired during preclinical stages) might influence and contribute to extracellular amyloid accumulations. 1,2 Autophagy impairments (which have been shown to become significant during the later stages of Alzheimers disease) might influence and contribute to intracellular amyloid accumulations. 3 Role of Autophagy in Amyloid Processing- Extracellular and Intracellular Amyloid 1 - Nilsson P. et al. "A secretion and plaque formation depend on autophagy", Cell Rep., vol 5, 2013, 61-69. 2 - Nilsson P., Saido T.C., "Dual roles for autophagy: degradation and secretion of Alzheimer's disease A peptide", Bioessays, vol. 36, 2014, 570-578. 3 - Nixon R.A., "Autophagy, amyloidogenesis and Alzheimer disease" J. Cell Sci., vol. 120, 2007, 4081-91.
9. 9. Extracellular Amyloid has been proposed to exert toxicity on cell membranes and neurotransmitter receptors. 1,2 Intracellular Amyloid has been proposed to disrupt the intracellular milieu of neurons, contributing to organelle pathology, including mitochondrial damage, and ER Stress. 3,4 Extracellular and Intracellular Amyloid 1 - Nixon R.A., "Autophagy, amyloidogenesis and Alzheimer disease" J. Cell Sci., vol. 120, 2007, 4081-91. 2 - Nixon R.A., "Alzheimer neurodegeneration, autophagy, and Abeta secretion: the ins and outs (comment on DOI 10.1002/bies.201400002)", Bioessays, vol. 36, 2014, 547. 3 - Umeda T., "Intraneuronal amyloid oligomers cause cell death via endoplasmic reticulum stress, endosomal/lysosomal leakage, and mitochondrial dysfunction in vivo", J. Neurosci. Res., vol. 89, 2011, 1031-1042. 4 - Wirths O., "Intraneuronal A accumulation and neurodegeneration: lessons from transgenic models" Life Sci., vol. 91, 2012, 1148-1152.
10. 10. Feed-Forward Interactions between Intracellular Calcium and Amyloid Ca2+ Amyloid 1 - Green K.N. and LaFerla F.M., "Linking calcium to Abeta and Alzheimer's disease", Neuron, vol. 59, 2008, 190-194. 2 - Demuro A. et al., "Calcium signaling and amyloid toxicity in Alzheimer disease", J. Biol. Chem., vol. 285, 2010, 12463-12468. 3 - De Caluw J. and Dupont G., "The progression towards Alzheimer's disease described as a bistable switch arising from the positive loop between amyloids and Ca(2+)", J. Theor. Biol., vol. 331, 2013, 12-18. 4 - Texid L. et al., Amyloid peptide oligomers directly activate NMDA receptors Cell Calcium, vol. 49, 2011, 184-190. 5 - Jensen L.E. et al., "Alzheimer's disease-associated peptide A42 mobilizes ER Ca(2+) via InsP3R-dependent and - independent mechanisms., Front. Mol. Neurosci., vol. 6:36, 2013.
11. 11. Abnormal Ca2+ signaling through plasma membrane channels Extracellular Amyloid Intracellular Amyloid Abnormal Ca2+ signaling through endoplasmic reticulum channels
12. 12. In neurons, Ca2+ in the cytoplasm mediates both Long-Term Potentiation (LTP) and Long-Term Depression (LTD). 1 Resting intraneuronal calcium levels in the cytoplasm ~ 100 nM. 2 Increased intracellular calcium concentrations have been observed in neurons from 3xTg-AD transgenic mice. 3 Models of Alzheimers disease suggest that increased resting intracellular calcium levels disrupt memory consolidation. 4 Aberrant intraneuronal calcium is potentially an early molecular occurrence in Alzheimers disease that contributes to cognitive symptoms. 4 Intracellular Calcium 1 - Malenka R.C. and Bear M.F., "LTP and LTD: an embarrassment of riches", Neuron, vol. 44, 2004, 521. 2 - Berridge M.J et al., "The versatility and universality of calcium signaling", Nat. Rev. Mol. Cell Biol., vol. 1, 2000, 1121. 3 - Lopez J.R. et al., Increased intraneuronal resting [Ca2+] in adult Alzheimer's disease mice, J. Neurochem., vol. 105, 2008, 262-271. 4 - Bezprozvanny I. and Hiesinger P.R., The synaptic maintenance problem: membrane recycling, Ca2+ homeostasis and late onset degeneration, Mol. Neurodegener., vol. 8, 2013, 23.
13. 13. Linking Neuronal Hyperactivity with Calcium Signaling, Amyloid, Mitochondrial dysfuntion, ER Stress, and Neurodegeneration Increased Activity Is Paired With Calcium Signaling and Calcium Influx Metabolic Stress and ROS 1,2 Calcium Derangements 3,4 Increased Synaptic Exocytosis 5,6 Progressive Oxydative Damage Mitochondrial Dysfunction Diminished Metabolic Capacity ER Stress/UPR/Inflam./Misfolding Synaptic Dysfunction Excitotoxic Damage ER Stress/UPR/Inflam./Misfolding Interstitial Amyloid Amyloid Deposits 1 Celsi F. et al., Mitochondria, calcium and cell death: a deadly triad in neurodegeneration Biochim. Biophys. Acta., Vol. 1787, 2009, 335-344. 2 - Cal T. et al., Mitochondrial Ca2+ and neurodegeneration. Cell Calcium, vol. 52, 2012, 73-85. 3 Szydlowska K. and Tymianski M., Calcium, ischemia and excitotoxicity Cell Calcium, vol. 47, 2010, 122-129. 4 Zhang H. et al., Calcium signaling, excitability, and synaptic plasticity defects in a mouse model of Alzheimer's disease J. Alzheimers Dis., vol. 45, 2015, 561-580. 5 Cirrito J.R. et al., "Synaptic activity regulates interstitial fluid amyloid-beta levels in vivo.", Neuron, vol. 48, 2005, 913-922. 6 - Bero A.W. et al. Neuronal activity regulates the regional vulnerability to amyloid- deposition Nat. Neurosci., vol 14, 2011, 750-766.
14. 14. Lithium has been shown to antagonize NMDA receptors -Nonaka et al. EC50 of Li 1.3 mEq/L, 67 days of Li required for maximum effect, 24 h of Li was ineffective; Hashimoto et al. EC 50 of Li 0.4 mEq/L, At 1.0 mEq/L 56 days required for maximum effect, 1 h of Li was ineffective. 1,2 Lithium has been shown to inhibit Inositol Monophosphatase (IMP) and reduce Inositol Triphosphate (IP3) -In vitro experiments by Hallcher et al. (1980) and Berridge et al.(1982) have shown that lithium inhibits IMP half-maximally at 0.80 mEq/L and 1.0 mEq/L respectively. 3,4 -Lithium has been shown to dose-dependently reduce carbachol-stimulated IP3 accumulation at concentrations as low as 0.1 mEq/L, and half-maximally at 1 mEq/L. 5 Lithium has been shown to reduce intracellular calcium ion concetrations This effect was observed in a 7 day protocol of lithium at 1.0 mEq/L. 6 How can lithium influence calcium signaling? Therapeutic Concentrations of Lithium 0.6 1.2 mEq/L (FDA) 1 - Nonaka S. et al., Chronic lithium treatment robustly protects neurons in the central nervous system against excitotoxicity by inhibiting N- methyl-D-aspartate receptor-mediated calcium influx, Proc. Natl. Acad. Sci. U. S. A., vol. 95, 1998, 2642-2647. 2 - Hashimoto R. et al., Lithium protection against glutamate excitotoxicity in rat cerebral cortical neurons: involvement of NMDA receptor inhibition possibly by decreasing NR2B tyrosine phosphorylation, J. Neurochem., vol. 80., 2002, 589-597. 3 - Hallcher L.M. and Sherman W.R., The effects of lithium ion and other agents on the activity of myo-inositol-1-phosphatase from bovine brain, J. Biol. Chem., vol. 255, 1980, 10896-10901. 4 - Berridge M.J. et al., Lithium amplifies agonist-dependent phosphatidylinositol responses in brain and salivary glands, Biochem. J., vol. 206, 1982, 587. 5 - Batty I. and Nahorski S.R., "Differential effects of lithium on muscarinic receptor stimulation of inositol phosphates in rat cerebral cortex slices", J. Neurochem., vol. 45, 1985, 1514-1521. 6 - Sourial-Bassillious N. et al., "Glutamate-mediated calcium signaling: a potential target for lithium action." Neuroscience. vol. 161, 2009, 1126-1134.
15. 15. Mg+2 and Li+ have similar ionic radii and charge (Li+ has a slightly smaller ionic radius compared the Mg+2, allowing Li+ to fit into Mg+2 substrates). Given the similarities between the two ions, Li + has been implicated in targeting substrates regulated by Mg+2. 1-4 Mg+2 sensitive targets include IMP and NMDA receptor channels and potentially, hundreds of other biological substrates regulated by Mg+2. Mg+2 also has similar physical properties with Ca+2, this might account for the inhibitory effects of Mg+2, and Li +, on NMDA receptor channel mediated Ca+2 influx. Lithium, Magnesium, and Calcium 1 - Birch N.J., Letter: Lithium and magnesium-dependent enzymes. Lancet, vol. 304, 1974, 965-966. 2 - Amari L., et al., Comparison of fluorescence, (31)P NMR, and (7)Li NMR spectroscopic methods for investigating Li(+)/Mg(2+) competition for biomolecules. Anal. Biochem., vol. 272, 1-7. 3 - Amari L., "Competition between Li+ and Mg2+ in neuroblastoma SH-SY5Y cells: a fluorescence and 31P NMR study", Biophys. J., vol. 76, 1999, 2934-2942. 4- Pasquali L. et al., "Intracellular pathways underlying the effects of lithium", Behav. Pharmacol., vol 21, 2010, 473-492.
16. 16. PHYSICOCHEMICAL PROPERTIES OF SOME ALKALI AND ALKALINE EARTH ELEMENTS * (Li) (Mg) (Ca) Atomic Radius 1.33 1.36 1.74 Crystal Ionic Radius 0.60 0.65 0.99 Corrected Hydrated Radius 3.40 4.65 3.21 Electronegativity 1.0 1.2 1.0 Polarizing Power 2.8 4.7 2.05 * Stern, K. H.; Amis, E. S., Chem. Rev., 1959, 59, 1. Lithium, Magnesium, and Calcium
17. 17. Lithium Lithium NMDA Antagonism IMP Inhibition Lowered Intracellular Calcium Intrusion from External Stores Reduced IP3 Lowered Intracellular Calcium Intrusion from Internal Stores ER Ca2+External Ca2+
18. 18. Lithium BACE Inhibitor Amyloid (A) (BACE Inhibition) Calcium dysregulation (NMDA Receptor Antagonism) (IMP Inhibition/IP3 lowered) Lowered Intracellular Calcium Reduced Amyloid (A) Ca2+ Amyloid (A) Lithium ER Ca2+External Ca2+ Amyloid (A)
19. 19. In the past decade, two observational studies, one in Brazil, and one in Denmark, have shown that subjects with bipolar disorder who are treated with lithium have a reduced prevalence of dementia. While this data suggests that continued use of lithium may reduce the risk for developing Alzheimers disease in asymptomatic adults, confounding factors could have affected the results. 1,2 1 - Nunes P.V. et al., "Lithium and risk for Alzheimer's disease in elderly patients with bipolar disorder", Br. J. Psychiatry, vol. 190, 2007, 359-360. 2 - Kessing L.V. et al., "Does lithium protect against dementia?", Bipolar Disord., vol. 12, 2010, 87-94. Repositioning Lithium for the Prevention of Neurodegenerative Disease
20. 20. 2015 The British Journal of Psychiatry A recently published observational study involving over 40,000 U.S. subjects in 8 states age 50 showed that subjects with bipolar disorder who received 301365 days of lithium had a reduced risk of developing dementia. PMID: 25614530 (hazard ratio = 0.77, 95% CI 0.60-0.99) Gerhard T. et al.., "Lithium treatment and risk for dementia in adults with bipolar disorder: population-based cohort study, Br. J. Psychiatry, 2015, 1-6, in press.
21. 21. Memantine + Levetiracetam + BACE Inhibitor * Combining Memantine + Levetiracetam + BACE inhibitor: A. to inhibit calcium influx from both external and internal calcium stores for a lithium-like effect with an improved side-effect profile, and reduced monitoring B. to inhibit the cleavage of Amyloid Precursor Protein (APP) by beta-secretase * U.S. Provisional Patent Application #US 62/143,057
22. 22. By antagonizing NMDA receptors, Memantine can inhibit the stimulation of neurons and inhibit external calcium ion influx. Memantine, NMDA Receptors, and External Calcium Influx
23. 23. Levetiracetam, and IP3R + RyR calcium induced calcium release (CICR) from ER stores Nagarkatti N. et al., Levetiracetam inhibits both ryanodine and IP3 receptor activated calcium induced calcium release in hippocampal neurons in culture, Neurosci. Lett., vol. 436, 2008, 289-293. Fukuyama K. et al., Levetiracetam inhibits neurotransmitter release associated with CICR Neurosci Lett., vol. 518, 2012, 69-74. By inhibiting IP3R and RyR calcium induced calcium release, Levetiracetam can reduce calcium ion influx from internal ER stores. 1,2
24. 24. In a recent clinical trial, subjects with amnesic mild cognitive impairments treated with levetiracetam showed: (1) improvements in memory task performance (2) reduced rates of elevated hippocampal dentate gyrus/CA3 activation. Levetiracetam and Neuronal Hyperactivity Bakker A. et al., Response of the medial temporal lobe network in amnestic mild cognitive impairment to therapeutic intervention assessed by fMRI and memory task performance, Neuroimage Clin., vol 7, 2015, 688-698.
25. 25. Levetiracetam BACE Inhibitor Amyloid (BACE inhibition) Calcium dysregulation (NMDAR Ca2+ influx antagonism) + (IP3R + RyR CICR inhibition) Lowered Intracellular Calcium Reduced Amyloid Ca2+ Amyloid Memantine ER Ca2+External Ca2+ Amyloid (A)
26. 26. Levetiracetam + BACE inhibitor * Combining levetiracetam and a BACE inhibitor to decrease ER calcium release and to reduce amyloid. * U.S. Provisional Patent Application #US 62/143,057
27. 27. Levetiracetam BACE Inhibitor Amyloid (BACE Inhibition) Calcium dysregulation (IP3R channel CICR Inhibition) (RyR channel CICR Inhibition) Decreased Calcium Induced Calcium Release (CICR) from ER stores Reduced Amyloid Ca2+ Amyloid Amyloid (A)ER Ca2+
28. 28. Wallace J., Calcium dysregulation, and lithium treatment to forestall Alzheimer's disease - a merging of hypotheses, Cell Calcium, vol. 55, 2014, 175-81. Additional Reading
29. 29. James Wallace M.D. Thank you