Review

Microtubule-associated protein
tau as a therapeutic target in
Alzheimers disease
1.

Introduction

2.

Mechanism of neurofibrillary
degeneration

3.

Regulation of tau

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phosphorylation
4.

Drug targets

5.

Expert opinion

Khalid Iqbal, Cheng-Xin Gong & Fei Liu

New York State Institute for Basic Research in Developmental Disabilities,

Department of Neurochemistry, Inge Grundke-Iqbal Research Floor, Staten Island, NY, USA

Introduction: Alzheimers disease (AD) is a major public health problem in

modern society and as yet, other than a few symptomatic drugs, there is no
disease-modifying treatment for this disease available.
Areas covered: Neurofibrillary pathology, which is made up from abnormally
hyperphosphorylated microtubule-associated protein tau, is both a hallmark
and key lesion of AD and related tauopathies. The density of neurofibrillary
pathology in the cerebral cortex correlates with the degree of dementia.
Both experimental and transgenic animal studies have consistently shown
that abnormal hyperphosphorylation of tau causes cognitive impairment.
Abnormal hyperphosphorylation of tau converts it from a microtubule
assembly-promoting to a microtubule-disrupting protein and promotes its
self-assembly into paired helical filaments. To date, the bulk of studies have
shown that abnormal hyperphosphorylation is the key gain of toxic function
step though some cell culture and transgenic mouse studies have also
reported that aggregated tau can lead to neurodegeneration. In this article,
we have reviewed data from our lab and that from PubMed search on
the molecular mechanism of tau pathology and the potential of tau as a
therapeutic target for AD and related disorders.
Expert opinion: In our opinion, inhibition of abnormal hyperphosphorylation
of tau is the most rational therapeutic target. Therapeutic approaches include
restoration of the activity of protein phosphatase-2A, which is the major
regulator of tau phosphorylation and the activity of which is compromised in
AD brain, inhibition of one or more tau protein kinases which include GSK-3b,
cyclin-dependent protein kinase-5, dual-specificity tyrosine phosphorylatedregulated kinase 1A, Ca2+/calmodulin-activated protein kinase II and casein
kinase I, enhancement of O-GlcNAcylation of tau, and tau immunization.
Keywords: abnormal hyperphosphorylation of tau, neurofibrillary pathology, protein
phosphatase-2A, tau immunotherapy, tauopathies
Expert Opin. Ther. Targets [Early Online]

1.

Introduction

Alzheimers disease (AD) is multifactorial and involves several different etiopathogenic mechanisms [1]. Less than 1% of AD cases are familial, caused by certain
amino acid substitution mutations in b-amyloid precursor protein (bAPP) or
presenilin-1 or presenilin-2 [2]. The remaining, over 99% of the cases, represent
the sporadic form of AD, which are apparently caused by several different etiological
factors, the nature of which remains uncertain. APO"4 is a risk factor for AD [3].
One copy of APO"4 increases the risk by ~ 3.5-fold and two copies of the allele
carry a risk of over 10-fold. APO"2 appears to nullify the APO"4 risk. Independent
of whether familial or sporadic and the etiology, AD is histopathologically characterized by neurofibrillary pathology made up of abnormally hyperphosphorylated
10.1517/14728222.2014.870156 2014 Informa UK, Ltd. ISSN 1472-8222, e-ISSN 1744-7631
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K. Iqbal et al.

Article highlights.
.

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Abnormal hyperphosphorylation of tau is a key

pathologic event involved in the loss of neuronal activity
that leads to a slow progressive neurodegeneration in
AD and related tauopathies.
The cytosolic abnormally hyperphosphorylated tau
sequesters normal tau in a non-saturation manner,
forming sedimentable oligomers and eventually paired
helical or straight filaments.
The oligomeric abnormally hyperphosphorylated tau and
not neurofibrillary tangles is the main deleterious state
of the protein that causes disruption of microtubule
network and consequently neurodegeneration.
The abnormal hyperphosphorylation of tau and the
resulting pathological protein are the most rational and
promising therapeutic targets.
Therapeutic approaches to neurofibrillary degeneration
in AD and related tauopathies include restoration of the
activity of PP2A, which is the major regulator of tau
phosphorylation and the activity of which is
compromised in AD brain and the brains of adults with
DS, inhibition of one or more tau protein kinases which
include GSK-3b, cdk5, Dyrk1A, CaMKinase II and casein
kinase I, enhancement of O-GlcNAcylation of tau,
modulation of the alternative splicing of tau to achieve
1:1 ratio of 3R:4R taus, and tau immunization.

This box summarizes key points contained in the article.

tau [4,5] and amyloid b (Ab) plaques [6-8]. In addition to AD,

in adults with Down syndrome (DS) and in every tauopathy,
tau pathology is made up of abnormally hyperphosphorylated
tau and is associated with cognitive impairment [9].
The abnormal hyperphosphorylation of tau protein seen as
intraneuronal neurofibrillary tangles, neuropil threads and as
dystrophic neuritis surrounding the Ab core in a plaque is a
histopathological hallmark of AD. The density of the neurofibrillary tangles, which are composed of paired helical filaments,
sometimes admixed with 15 nm straight filaments, both of
which are polymers of the abnormally hyperphosphorylated
tau [4,5], directly correlates with the degree of dementia [10,11].
The Ab plaque load, whereas, does not correlate with
dementia [10-12]. In addition to AD, adults with DS develop
both tau and Ab pathologies in the fourth decade of life. The
neurofibrillary pathology of abnormally hyperphosphorylated
tau in the absence of any Ab pathology is, however, seen in a
family of related neurodegenerative diseases called tauopathies.
These tauopathies include frontotemporal dementia with
Parkinsonism linked to chromosome 17 tau (FTDP-17 tau),
corticobasal degeneration, Picks disease, supranuclear palsy,
dementia pugilistica/chronic traumatic encephalopathy and
Guam Parkinsonism dementia complex. Every one of these
tauopathies results in cognitive impairment; the supranuclear
palsy cases with tau pathology in the brain stem show motor deficit. On the other hand, as many as ~ 30% of normal aged individuals show as many Ab plaques identical to those seen in AD
cases except lacking tau pathology in the dystrophic neurites.
2

Despite this clear evidence that Ab and tau pathologies can

occur independent of each other, the discovery of an AD causative mutation of bAPP in familial form of the disease [13] led to
the Amyloid Cascade Hypothesis, according to which Ab causes
the disease through induction of neurofibrillary pathology [14].
The immense popularity of the Amyloid Cascade Hypothesis since its report in 1992 has led to many attempts to
develop compounds that can inhibit Ab production, aggregation and or clearance. To date, these Ab-based therapeutic
attempts have been unsuccessful but many drugs, especially
Ab antibodies for immunotherapy, are still in different stages
of development and in clinical trials. Disappointing outcomes
of Ab-based therapeutic approaches have stimulated the
search for other, especially tau-based, drug development.
Neurons with neurofibrillary tangles apparently undergo a
slow progressive retrograde degeneration, leading to a loss of
neuronal plasticity but survive for many years though probably at a fraction of their normal functional level [15]. Thus
apparently a large window of opportunity exists to treat AD
by inhibiting neurofibrillary degeneration.
2.

Mechanism of neurofibrillary degeneration

Development of rational tau-based therapies requires an

understanding of the molecular mechanism of neurofibrillary
degeneration.
Tau is the major neuronal microtubule-associated protein
(MAP). In normal adult brain, there are six isoforms of tau,
which are products of alternative splicing of the pre-mRNA
coded by a single gene residing on chromosome 17 [16]. These
6 forms differ from one another by the presence (4 Repeat) or
absence (3 Repeat) of exon 10 which codes for the second of
the 4 microtubule-binding domains/repeats and the presence
(1N or 2N) or absence (0 N) of exon 2 or exon 3 which codes
the two 29 amino acid amino terminal inserts. Thus, the six
tau isoforms are 4R 0N, 4R 1N, 4R 2N, 3R 0N, 3R 1N and
3R 2N. In fetal human brain, only 3R 0N, the smallest
(352 amino acids) tau isoform, is expressed. In AD brain, all
six tau isoforms are seen abnormally hyperphosphorylated in
both cytosol [17] and in paired helical filaments that make the
neurofibrillary tangles [4,5]. Normal human brain tau contains
2 -- 3 moles phosphates/mole of the protein, while the AD
abnormally hyperphosphorylated protein has a phosphorylation stoichiometry of at least 6 -- 9 [18]. In AD as much
as ~ 40% of the abnormally hyperphosphorylated tau is
recovered in the brain cytosol [18]. This pool of pathological
tau termed AD abnormally hyperphosphorylated tau (AD
P-tau) is cytosolic in contrast to neurofibrillary tangles, is abnormally hyperphosphorylated, is in oligomeric form and, unlike
normal tau which is soluble, it sediments at 200,000  g. There
is as much normal tau in AD brain as in age-matched non-neurological aged brain. However, there is an ~ 4 -- 5-fold higher
level of total tau in AD brain and this increase is all in the
form of the abnormally hyperphosphorylated tau [19]. Apparently the turnover rate of the abnormally hyperphosphorylated

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MAPT as a therapeutic target in Alzheimers disease

tau is very much slower due to its resistance to calcium-activated

neutral proteases than the normal tau [20,21].
Unlike normal tau, the cytosolic AD P-tau does not interact
with tubulin and thus does not promote its assembly into
microtubules [22,23]. Instead, AD P-tau binds to normal tau,
forming oligomers, which, unlike normal tau, sediment at
200,000  g [18]. The sequestration of normal tau by AD
P-tau disrupts microtubule network [22,24]. Tau oligomers
assemble into filaments [25]. The self-assembly of tau into paired
helical filaments is promoted by its abnormal hyperphosphorylation [21,26,27]. The AD P-tau also sequesters MAP1 and
MAP2, causing disruption of microtubules in vitro. However,
this interaction between AD P-tau and MAP1 and MAP2
does not lead to the formation of any filaments [28]. Both the
sequestration of normal MAPs by AD P-tau and its selfassembly into paired helical filaments are due to the abnormal
hyperphosphorylation of tau because its dephosphorylation by
phosphatase results in a loss of these activities and the dephosphorylated AD P-tau behaves like normal tau [20-22,25,27,28].
The inhibitory deleterious activities of AD P-tau are apparently lost when it polymerizes into filaments. The filamentous
abnormally hyperphosphorylated tau is apparently inert; it
neither interacts with tubulin nor affects interaction and biological activity of normal tau in promoting microtubule
assembly [20,23,29].
The biological activity of tau is regulated by its degree of
phosphorylation and hence its hyperphosphorylation is not
necessarily pathological. In normal brain from anesthetized
individuals, especially during development, tau is hyperphosphorylated but not to the same extent and not at all the sites
seen in AD brain [30,31]. Hypothermia such as during hibernation in animals also causes transient hyperphosphorylation of
tau [32-35]. Unlike the transiently hyperphosphorylated tau,
the AD P-tau is characterized by i) its ability to sequester normal MAPs and cause disruption of microtubules and ii) its
self-assembly into paired helical filaments. Like human tau,
recombinant murine tau when abnormally hyperphosphorylated with brain protein kinases self-assembles into paired
helical filaments in vitro [36]. Thus, the transient hyperphosphorylation of tau such as that seen during anesthesia and
hibernation in animals is probably not pathological and could
be initiated to prevent neurons from undergoing apoptosis;
hyperphosphorylation of tau has been reported to prevent
neuronal apoptosis [37].
3.

Regulation of tau phosphorylation

Role of tau protein kinases and phosphatases

The phosphorylation state of a protein is a product of the sum
of the activities of protein kinases and phosphatases to which
the protein serves as a substrate. Tau protein has 80 Ser/Thr
potential phosphorylation sites and is phosphorylated by several
protein kinases. Tau protein kinases include both prolinedirected protein kinases (PDPKs) such as glycogen synthase
kinase-3b (GSK-3b), cyclin-dependent protein kinase-5
3.1

(cdk5), dual-specificity tyrosine phosphorylated-regulated

kinase 1A (Dyrk1A) and non-PDPKs such as calcium
calmodulin-activated protein kinase II (CaMKinase II), cyclic
AMP-dependent protein kinase A (PKA) and casein kinase-1
(CK-1); phosphorylation of tau by a non-PDPK generally
primes it for a higher level of phosphorylation by a PDPK [38].
All of these kinases have been found to be colocalized with neurofibrillary tangles in the AD brain [39-45]. However, to date,
there are no compelling data that show a sustained elevation
of tau protein kinase activity in AD brain. On the other hand,
protein phosphatase-2A (PP2A), which is the major regulator
of tau phosphorylation [46,47] and which accounts for over
70% of the total Ser/Thr-phosphatase activity in the human
brain [48], is compromised in AD brain [49,50].
PP2A is a trimeric holoenzyme consisting of a scaffolding A
subunit, a variable regulatory B subunit which determines its
subcellular localization and substrate specificity, and a
catalytic C subunit. There are two heat- and acid-stable
proteins, I1PP2A and I2PP2A, which regulate its activity by
inhibiting it [51-53]. Both mRNA and protein expressions of
I1PP2A, also known as mapmodulin, pp32, LANP and putative
histocompatibility leucocyte antigen class II associated with
protein-I (PHAPI), and I2PP2A, also known as SET, PHAPII
and TAF1b, are elevated in the affected areas of AD brain.
Furthermore, in the case of I2PP2A/SET, a 277-amino-acidlong polypeptide, which is primarily a nuclear protein, is
cleaved at Asn175 and is translocated from the neuronal nucleus
to the cytoplasm in AD brain [54]. Both the resulting N-terminal
(I2NTF) and C-terminal (I2CTF) fragments of I2PP2A inhibit
PP2A activity and consequently lead to the abnormal
hyperphosphorylation of tau [55].
The cleavage of I2PP2A into I2NTF and I2CTF is catalyzed by
a lysosomal hydrolase, the asparaginyl endopeptidase (AEP)
also known as legumain [56]. A 56-kDa pro-AEP is known
to undergo autocatalytic cleavage under acidic conditions to
a proactive 46-kDa and then an active 36-kDa AEP [57,58].
Ischemia and hypoxia, especially in association with hyperglycemia in diabetics and traumatic brain injury, cause acidosis
of the brain. In AD brain, the level of 36-kDa active AEP is
increased with a corresponding decrease in the level of the
56-kDa pro-AEP. Furthermore, the active AEP and I2PP2A
are translocated, respectively, from neuronal lysosomes and
nucleus to the cytoplasm and localized with neurofibrillary
tangles in AD brain [59]. Activation of AEP by acidic pH in
metabolically active rat brain slices leads to cleavage of I2PP2A
into I2NTF and I2CTF, inhibition of PP2A and abnormal
hyperphosphorylation of tau [59].
Transduction of the brain with adeno-associated virus
serotype 1 containing I2NTF and I2CTF or I2CTF alone causes
inhibition of PP2A, abnormal hyperphosphorylation of tau,
loss of synaptic plasticity and cognitive impairment in
rats [60,61]. Inhibition of PP2A leads to abnormal hyperphosphorylation of tau not only by a direct decrease in its dephosphorylation but also through activating several tau protein
kinases, the activities of which are regulated by it [38].

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K. Iqbal et al.

PP2A activity is also negatively regulated by phosphorylation of its catalytic subunit PP2Ac at Tyr307 by Src [62] as
well as its demethylation at Leu309 by methyl esterase [63,64].
Both an increase in phosphorylation at Tyr307 [65] and
demethylation [66] of PP2Ac have been reported in AD brain.
Role of O-GlcNAcylation and other
posttranslational modifications in regulating
phosphorylation of tau

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3.2

In addition to protein kinases and phosphatases, tau phosphorylation is also regulated by other posttranslational modifications,
such as O-GlcNAcylation, truncation and acetylation.
In the normal brain, tau is highly modified by O-GlcNAcylation, a dynamic protein posttranslational modification, by
which O-linked b-N-acetylglucosamine (O-GlcNAc) is transferred enzymatically from a UDP-GlcNAc donor to the
hydroxyl group of serine or threonine residues of proteins [67,68].
At least five serine or threonine residues of tau (Thr123, Ser208,
Ser238, Ser400 and one of Ser409, Ser412 or Ser413) are modified by O-GlcNAc [69-71]. We previously demonstrated that
inhibition of O-GlcNAcylation leads to hyperphosphorylation
of tau in cultured cells and in rat brain slices [68]. OGlcNAcylation also serves as a sensor of intracellular glucose
metabolism [72] because the UDP-GlcNAc donor for OGlcNAcylation is formed from glucose metabolism via the hexosamine biosynthetic pathway. Experimental reduction of brain
glucose metabolism leads to decreased O-GlcNAcylation and
increased phosphorylation of tau in vivo [73,74]. Inhibition of
protein O-GlcNAcylation induces hyperphosphorylation of
tau in rat brain [74]. More importantly, global O-GlcNAcylation
of proteins, especially of tau, is decreased in AD brain, and the
decrease in O-GlcNAcylation correlates to hyperphosphorylation of tau [74]. Furthermore, hyperphosphorylated tau purified
from AD brains contains approximately five-fold less OGlcNAc than normal tau [74]. Thus, tau pathology and neurodegeneration can be caused by impaired brain glucose metabolism,
which occurs prior to the appearance of any clinical symptoms,
through the downregulation of tau O-GlcNAcylation in AD [75].
Several studies have demonstrated that limited truncation
of tau promotes its phosphorylation, and both truncation
and hyperphosphorylation occur in AD brain [76,77]. In AD,
Picks disease and progressive supranuclear palsy, tau is truncated by caspases at Asp421, which appears to precede
hyperphosphorylation and filament formation [78-82]. Tau
truncation at Asp421 and hyperphosphorylation are also
seen in the brain and spinal cord of a mouse model of tauopathies (overexpressing human P301S tau) that recapitulates the
essential molecular and cellular features of the human tauopathies, including tau hyperphosphorylation, tau filament
formation and neurodegeneration [83]. In addition, tau truncation at Glu391 is seen in AD brain [84,85]. A mouse model
expressing human tau truncated at Glu391 develops pretangle
pathologic changes in tau, including hyperphosphorylation,
somatodendritic redistribution, formation of pathologic
4

conformations and accumulation of insoluble tau [86].

A transgenic rat model expressing a human tau truncated at
both the N- and C-terminus (3R tau151 -- 391)develops
tau hyperphosphorylation and progressive age-dependent
neurofibrillary degeneration in the brain [87].
It has been reported that tau is acetylated at Lys280 in AD
brains but not in healthy control brains, and the acetylation
of tau at this residue inhibits tau-dependent microtubule
assembly, which would facilitate phosphorylation, and fibrillization of tau [88,89]. On the other hand, acetylation of tau at
the KXGS motifs is observed in normal brain, and this modification is decreased in the brains of patients with AD and in
a mouse model of tauopathy [90]. Acetylation of tau on the
KXGS motifs inhibits phosphorylation on this same motif,
and also prevents tau aggregation. Thus, the modulation of
tau phosphorylation by acetylation could be site-specific.

Role of point mutations and alternative splicing

of tau in regulating phosphorylation of tau

3.3

Discovery of tau gene mutations associated with FTDP-17

tau [91-93] provided a clear and direct evidence that alterations
in tau alone could cause neurodegenerative disease, which
strongly suggests that aberrant tau plays a critical role in the
pathogenesis of AD and related tauopathies. To date, at least
46 mutations associated with FTDP-17 tau or related disorders have been identified (Figure 1). Majority of mutations
clusters in and around the microtubule binding repeats
encoded by exons 9, 10, 11 and 12, suggesting that alteration
of interaction between tau and microtubules may be involved
in neuronal degeneration and death in these families.
Both missense and silent mutations have been found in
FTDP-17 and related tauopathies. Missense mutations, including deletion mutations, commonly appear to impair tau binding
to microtubules and the ability of tau to promote microtubule
assembly. The silent mutations affect the alternative splicing of
tau exon 10, leading to changes of the ratio of 3R-tau and 4Rtau. Some missense mutations also modulate the alternative slicing of tau exon 10. Almost half of the disease-associated tau
mutations affect the alternative splicing of tau exon 10 (Figure 1).
Most of them are located within or near exon 10. Majority of
the disease-causing mutations promotes tau exon 10 inclusion,
resulting in an increase expression of 4R-tau (Figure 1), but
D280K, E9-15, E9+33, E10+4, E10+19 and E10+29 promote
tau exon 10 exclusion and cause an increase of 3R-tau expression. In the brains of patients with E10+19 and E10+29 mutaations, no insoluble tau is observed, suggesting that increases in
soluble 3R-tau could be responsible for frontotemporal dementia [94]. In addition, in individuals with fronto-temporal lobar
dementia (FTLD)-associated mutations, including L266V,
G272V, Q336R, E342V, K369I and G389R, only 3R-tau isoforms are present in Pick bodies [95,96], suggesting that these
mutations may lead to increased tau exon 10 exclusion. However, the effect of these mutations on tau exon 10 splicing is
unclear. Discovery of the splicing mutations in FTDP-17 tau

Expert Opin. Ther. Targets (2014) 18(3)

23

10
E10

E9+33

L266V
G272V

E9

Mutations that
alter tau exon 10 splicing

E9+33

4R-tau

11

12

G389R
R406W
N410H
T427M
13

14

E11 E12

E342V

A152T

K257T
1260V
L266V
G272V
G273R

G335S
G335V
Q336R
V337M
E342V
S352L
L315L S356T
L315R V363A
K317M V363I
S320F P364R
S320Y G366R
P332S K369I

N279K
K280
L284L
296N, N296N, N296H
P310S
G303V
S305S, S305N, S305I
E10+3
E10+4
E10+11
S10+12
E10+13
E10+14
E10+16
E10+19
E10+29

Exon

E9-15

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R5H E55R
R5L V75A Q124E

E9-15

Tau mutations associated with

FTDP-17-tau and related tauopathies

N279K
K280
L284L
L284R
N296N
N296H
N296
P301T
P301L
P301S
G303V
G304S
S305I
S305N
S305S

E10+3, 4, 11, 12, 13,14, 16, 19, 29

MAPT as a therapeutic target in Alzheimers disease

Figure 1. Tau mutations that have been found to cause FTDP-17 tau. To date, > 50 mutations in tau that cause various
tauopathies (upper labels) have been reported. Among them, about half of them (lower labels) alter the alternative splicing
of tau exon 10, resulting in changes in the ratio of 4R-tau and 3R-tau. E, exon; arrow head, changes in 4R-tau/3R-tau ratio.

suggests that a balanced expression of 3R-tau and 4R-tau is critical for maintaining normal brain function and disruption of
this balance is sufficient to cause neurodegeneration. 4R-taus
bind microtubules and promote its assembly more readily
than 3R-taus, and alteration of the balance between 3R-tau
and 4R-tau expression leads to unbound protein.
Normal adult human brain expresses approximately equal
levels of 3R-tau and 4R-tau. Thus, it is possible the 1:1 ratio of
3R-tau/4R-tau is required for maintaining the normal dynamics
of microtubules in mature human neuron. Excess amounts of
either 3R-tau or 4R-tau due to dysregulation of tau exon 10 splicing could result in increased free 3R-tau or 4R-tau in cytoplasm. Compared to microtubule-bound tau, free tau is more
vulnerable for hyperphosphorylation and aggregation into
neurofibrillary tangles (NFTs) [97]. In addition, tau isoforms
might be phosphorylated differentially. In vitro 4R-tau is a
more favorable substrate for phosphorylation by rat brain protein
kinases and phosphorylated faster and to a higher extent than
3R-tau at multiple sites, including Ser199, Ser202, Thr205,
Thr212, Ser214, Thr217, Thr231, Ser235, Ser262, Ser396,
Ser404 and Ser422 [98].
Substrate regulation of tau phosphorylation
In the normal neuron, almost all taus are bound to microtubules
and is protected from abnormal hyperphosphorylation because
3.4

free tau is a much preferred substrate than microtubule-bound

tau for brain protein kinases [97]. Thus, any posttranslational
modifications which result in its dissociation from microtubules, especially in association with a downregulation of a tau
protein phosphatase-kinase balance as in AD and DS brain [99],
will probably result in tau pathology. FTDP-17 missense mutations R406W, V337M, G272V and P301L make tau more
favorable substrates for abnormal hyperphosphorylation by
brain protein kinases in vitro [98].
Both in vitro [29] and in vivo [100] studies have suggested
that polymerization of abnormally hyperphosphorylated tau
into filaments reduces its inhibitor/neurotoxic activity. This
is consistent with the fact that neurons with neurofibrillary
tangles escape apoptosis and survive for many years [15,37].
In AD brain, truncation of tau both at Glu391 [76] and
Asp421 [101] in neurofibrillary tangles has been reported and
these truncations promote its abnormal hyperphosphorylation
and polymerization into filaments. The truncations probably
make tau more readily abnormally hyperphosphorylated
and possibly more aggregant than the full-length protein.
Transgenic rats overexpressing tau151-391 show tau abnormal
hyperphosphorylation, many neurofibrillary tangles and cognitive impairment [102]. However, at present, it is not established whether the cognitive impairment and mortality at
around 6 -- 9 months seen in these animals are due to the

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K. Iqbal et al.

Neurofibrillary degeneration
Protein phosphorylation/dephosphorylation
imbalance
Activate PP2A
Inhibit tau protein kinases such
as GSK-3, CDK5, Dyrk1A, CK1
and CaMKII

Promote O-GlcNAcylation of tau

by increasing brain glucose
uptake/metabolism

Abnormal hyperphosphorylation and aggregation of tau

Remove altered tau by active or
passive immunization

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Sequestration of normal tau, MAP1 and MAP2 by

the hyperphosphorylated tau
Inhibit sequestration by neutralizing
hyperphosphorylated tau

Disassembly of microtubules

Self assembly of
hyperphosphorylated tau

Stabilize microtubule
network

Inhibit tau aggregation

Compromised
axoplasmic flow

Neurofibrilary tangles

Retrograde degeneration
(loss of synapses)
Enhance neurogenesis
Death of neurons

Increase neuronal
plasticity

Dementia

Figure 2. Tau-based therapeutic approaches. Abnormal hyperphosphorylation of tau is the key deleterious step that leads to
neurofibrillary degeneration and dementia in AD and related tauopathies. Inhibition of the abnormal hyperphosphorylation
of tau combined with rescue of the neurogenesis and neuroplasticity deficits is the most rational and promising therapeutic
approach to AD.

cytosolic/oligomeric abnormally hyperphosphorylated tau or

the neurofibrillary tangles or both.
4.

Drug targets

To date, the bulk of the data suggests i) that neurofibrillary

degeneration involves abnormal hyperphosphorylation of tau,
ii) that the pre-filamentous state akin to tau oligomers is probably the most deleterious stage, and iii) that decreased PP2A
activity is pivotally involved in the pathology. Thus, the abnormally hyperphosphorylated tau is one of the most rational and
promising therapeutic targets for AD, adults with DS and for
other related tauopathies (Figure 2). Rational therapeutic
6

approaches include the inhibition of the abnormal hyperphosphorylation of tau, inhibition of tau truncation, increase in
clearance of the pathological tau and modulation of the alternative splicing of tau to achieve equal levels of 3R and 4R taus.
One of the most promising approaches and one with most
compelling data for inhibition of the abnormal hyperphosphorylation of tau is to rescue PP2A activity which is compromised
in AD brain. The loss of PP2A activity may be rescued by inhibition of either AEP, which can prevent cleavage and translocation of I2PP2A and the downstream inhibition of PP2A or by
directly inhibiting the activities of I2PP2A and I1PP2A. Other
approaches to rescue the PP2A deficit are to increase methylation of PP2Ac by inhibiting the activity of the PP2Ac methyl

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MAPT as a therapeutic target in Alzheimers disease

esterase or reduce the phosphorylation of PP2Ac at Tyr307 by

inhibiting Src kinase. In an adeno-associated virus-mediated
overexpression of I2NTF-CTF rat model in which demethylation
of PP2Ac is increased, we have observed a rescue of PP2Ac
methylation and of cognitive impairment by chronic treatment
with a methyl esterase inhibitor.
Inhibition of tau protein kinases is another approach to
inhibit abnormal hyperphosphorylation of tau. Here it is important to use either a broad PDPK inhibitor which can inhibit at
least both GSK-3b and cdk5 or a broad non-PDPK inhibitor
against CaMKII, PKA and casein kinase I. A specific inhibitor
of only one PDPK or non-PDPK is unlikely to be successful
because tau can be abnormally hyperphosphorylated by more
than one combination of a non-PDPK and a PDPK [27].
Phosphorylation of tau can also be regulated by its
O-GlcNAcylation. A promising approach is to rescue the OGlcNAcylation deficit that occurs in AD brain [68].
O-GlcNAcylation can be increased by either increasing the level
of the cosubstrate UDP-GlcNAc by increasing the activity of
GFAT or directly administering glucosomine-6-P or glucosamine or inhibiting the activity of O-GlcNAclase (OGA).
A potent selective inhibitor of OGA called thiamet-G has
been recently developed [103] and is in clinical trials for AD.
Calpain I and caspase-3 are believed to be involved in the
truncation of tau at Glu391 and Asp421, respectively. Inhibition of these proteases can be explored to inhibit these
truncations.
Both compromised proteosome [104] and autophagic [105,106]
activities have been implicated in AD [107]. Thus, clearance of
the pathological tau by stimulation of proteosome for soluble
and autophagy for filamentous protein is also the subject of
several recent studies [107].
The 2007 report of Asuni et al. [108] demonstrated the possibility of tau immuno therapy. Several labs have since reported
successful removal of abnormally hyperphosphorylated tau,
both by active and passive tau immunization [109-111]. Currently, Axon Neuroscience, Vienna, Austria, is conducting a
Phase I clinical trial for an active immunization tau vaccine.
Finally, the abnormal hyperphosphorylation can also be
attenuated by modulating upstream pathways such as increasing the expression of brain-derived neurotrophic factor which,
through activation of the PI3 kinase-AKT-GSK-3b, was
reported to attenuate hyperphosphorylation of tau [112].
5.

Expert opinion

encephalopathy and Guam Parkinsonism dementia complex.

The density of neurofibrillary tau pathology in the neocortex
directly correlates with the degree of dementia. In cases of progressive supranuclear palsy where the tau pathology is mostly in
the brain stem, it is correlated with motor impairment. The
facts that both missense mutations and intronic mutations
that alter the alternative splicing of tau cause FTDP-17 tau,
and that as many as ~ 30% of normal aged people have as
much Ab plaque load as typical cases of AD, make a compelling
case for the development of tau-based therapeutics.
The last 25 years of the AD field have been very much Ab
centric-driven by the Amyloid Cascade Hypothesis. Most of
the therapeutic clinical trials for AD have been either inhibition of the formation or aggregation or the clearance of Ab.
Unfortunately, to date, all of the Ab-based therapeutic clinical
trials have been unsuccessful. In the case of Ab immunotherapy, the AN1792 Ab vaccine clinical trial, although treatment
was effective in removing the plaques, did not reduce tau
pathology or show any benefit in the clinical state of the
patients [114]. Both the human data and preclinical studies
using experimental or transgenic animal models of tau pathology strongly suggest a causative role of neurofibrillary degeneration in cognitive impairment [60,100]. Several approaches can
be used to inhibit neurofibrillary degeneration. These include
inhibition of abnormal hyperphosphorylation of tau by
increase in PP2A activity; inhibition of tau protein kinases
such as GSK-3b, Dyrk1A, cdk5, CaMKII and CK-1; increase
in O-GlcNAcylation of tau by increasing brain glucose uptake;
inhibition of aggregation of hyperphosphorylated tau by using
tau aggregation inhibitors; clearance of tau pathology by active
or passive tau immunization; and stabilization of the microtubule network. However, both in AD and in transgenic mouse
models of AD pathology, the loss of neuronal plasticity apparently precedes the formation of any overt Ab plaques and neurofibrillary tangles. In transgenic AD mouse models, the
decrease in the dentate gyrus neurogenesis and the loss of neuronal plasticity correlate with cognitive impairment and precedes the occurrence of Ab plaques and tau pathology [115].
In our opinion the most effective rational treatment for AD
could require both inhibition of neurofibrillary degeneration
and rescue of neurogenesis and neuronal plasticity deficits.

Acknowledgment
We thank J Murphy for secretarial assistance.

Microtubule-associated protein tau is abnormally hyperphosphorylated and in this altered form is polymerized into paired
helical filaments/neurofibrillary tangles in the brains of patients
with AD and adults with DS [4,5,17,113]. The tau pathology made
up of the abnormally hyperphosphorylated protein in the
absence of any Ab pathology is also a hallmark of several other
neurodegenerative diseases called tauopathies which include
FTDP-17 tau, Pick disease, corticobasal degeneration, progressive supranuclear palsy, dementia pugilistica/chronic traumatic

Declaration of interest
Studies from our labs were supported in part by the New York
State Office of People with Developmental Disabilities; NIH
grants AG019158, TW008744 and AG038538; Alzheimers
Association grants IIRG-00-2002, HRG-05-13095, and
NIRG- 08-91126, and Zenith Award ZEN-12-231433; and a
grant, #20121203, from the Alzheimers Drug Discovery
Foundation.

Expert Opin. Ther. Targets (2014) 18(3)

K. Iqbal et al.

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Expert Opin. Ther. Targets (2014) 18(3)

Affiliation

Khalid Iqbal1 PhD,

Cheng-Xin Gong2 MD MS & Fei Liu3 PhD

Author for correspondence

1
Chairman,
New York State Institute for Basic Research in
Developmental Disabilities,
Department of Neurochemistry,
Inge Grundke-Iqbal Research Floor, 1050 Forest
Hill Road, Staten Island, NY 10314, USA
Tel: +1 718 494 5259;
E-mail: khalid.iqbal.ibr@gmail.com
2
Laboratory Head,
New York State Institute for Basic Research in
Developmental Disabilities,
Department of Neurochemistry, Brain
Metabolism Laboratory, Inge Grundke-Iqbal
Research Floor, 1050 Forest Hill Road, Staten
Island, NY 10314, USA
3
Laboratory Head,
New York State Institute for Basic Research in
Developmental Disabilities, Molecular
Neuroscience, Department of Neurochemistry,
Inge Grundke-Iqbal Research Floor, 1050 Forest
Hill Road, Staten Island, NY 10314, USA