CELLULAR BASIS OF ALZHEIMERS DISEASE AND ITS INNOVATIVE THERAPY

ABSTRACT: Alzheimers disease is the most common form of neurodegenerative disease. A characteristic feature of the disease is the presence of Amyloid- which either in its soluble oligomeric form or in the plaque associated form is casually linked to neurodegeneration. Amyloid peptide is liberated from the membrane-spanning-amyloid precursor protein by sequential proteolytic processing employing & Secretases. All these proteins involved in the production of amyloid peptide or membrane associated and hence, membrane trafficking and cellular compartamentalization play important roles. In this review we summarize the key cellular events that lead to the progression of alzheimers disease. Genetic and biological studies provide evident that the production and deposition Amyloid peptides contribute to the etiology of Alzheimers disease. -Secretase is the Pivotal enzyme involved amyloid -production. Inhibiting this enzyme could provide an effective therapy for Alzheimers disease. This review focus on studies of -secretase structure and its role in amyloid peptide generation. Also it highlights the involvement of -secretase in other cell signaling pathway. The interaction between the -secretase and its inhibitors also discussed which may be helpful in developing effective and selective -secretase inhibitors as drugs for the treatment of Alzheimers disease.

DISEASE CHARACTERISTICS: DEMENTIA:

Dementia is a clinical syndrome characterized by deficits in multiple areas of cognition that cannot be explained by normal aging, a noticeable decline in function, and an absence of delirium.1 In addition, neuropsychiatric symptoms and focal neurological findings are usually present.1 Dementia is further classified based on etiology. Alzheimer's disease (AD) is the most common cause of dementia, followed by mixed AD and vascular dementia, vascular dementia, Lewy body dementia (DLB), and frontotemporal dementia.1
TYPES OF DEMENTIA:

Dementia of the Alzheimer type: It is characterized by gradual onset, continuing cognitive decline, cannot be due to other causes of progressive cognitive decline, and cannot occur exclusively during the course of delirium.5

Vascular dementia: It can have 2 pathologies: large-vessel disease or small-vessel disease. Large-vessel disease leads to infarctions in the cortical region of the brain, whereas small-vessel disease is seen in the subcortical brain regions and is often the result of hypertension, diabetes, or blood vessel damage.6 Frontotemporal dementia: As its name implies, frontotemporal dementia is caused by damage to the anterior frontal and temporal lobes of the brain, and early symptoms are often behavioral and language-based.4

Lewy body dementia (DLB):

DLB is characterized by the presence of alpha-synuclein protein aggregates (Lewy bodies) in the substantia nigra and cortex.4 Because these aggregates are also seen in idiopathic Parkinson's disease, DLB can present with features of Parkinson's disease, such as tremor, bradykinesia, rigidity, and postural instability.4 Other defining clinical symptoms of DLB are visual hallucinations and memory loss attributed to an acetylcholine deficit.4

Pathophysiology: Neuropathology:
Alzheimer's disease is characterised by loss of neurons and synapses in the cerebral cortex and certain subcortical regions. This loss results in gross atrophy of the affected regions, including degeneration in the temporal lobe and parietal lobe, and parts of the frontal cortex and cingulate gyrus.[34] Studies using MRI and PET have documented reductions in the size of specific brain regions in people with AD as they progressed from mild cognitive impairment to Alzheimer's disease, and in comparison with similar images from healthy older adults.[56] Both amyloid plaques and neurofibrillary tangles are clearly visible by microscopy in brains of those afflicted by AD.[11] Plaques are dense, mostly insoluble deposits of amyloid-beta peptide and cellular material outside and around neurons. Tangles (neurofibrillary tangles) are aggregates of the microtubule-associated protein tau which has become hyperphosphorylated and accumulate inside the cells themselves. Although many older individuals develop some plaques and tangles as a consequence of aging, the brains of people with AD have a greater number of them in specific brain regions such as the temporal lobe.[57] Lewy bodies are not rare in the brains of people with AD.[58]

Plaques & Tangles

Disrupt all three processes
Communication (sending messages) Metabolism (turning chemicals and nutrients into energy to keep neurons working) Repair (keeping long-lived neurons in good working order)

Cause nerve cells to stop working, lose connections w/ other cells and eventually die Destruction causes memory failure, personality changes, etc. Find abundance of -amyloid plaques and neurofibrillary tangles, especially in regions for memory

Neurofibrill
Biochemical characteristics

Alzheimer's disease has been identified as a protein misfolding disease, or proteopathy, due to the accumulation of abnormally folded A-beta proteins in the brains of AD patients.[1] A-beta, also written A, is a short peptide that is a proteolytic byproduct of the transmembrane protein amyloid precursor protein (APP), whose function is unclear but thought to be involved in neuronal development. The presenilins are components of a proteolytic complex involved in APP processing and degradation.[3] Although amyloid beta monomers are soluble and harmless, they undergo a dramatic conformational change at sufficiently high concentration to form a beta sheet-rich tertiary structure that aggregates to form amyloid fibrils[6] that deposit outside neurons in dense formations known as senile plaques or neuritic plaques, in less dense aggregates as diffuse plaques, and sometimes in the walls of small blood vessels in the brain in a process called amyloid angiopathy or congophilic angiopathy. AD is also considered a tauopathy due to abnormal aggregation of the tau protein, a microtubuleassociated protein expressed in neurons that normally acts to stabilize microtubules in the cell cytoskeleton. Like most microtubule-associated proteins, tau is normally regulated by phosphorylation; however, in AD patients, hyperphosphorylated tau accumulates as paired helical filaments[7] that in turn aggregate into masses inside nerve cell bodies known as neurofibrillary tangles and as dystrophic neurites associated with amyloid plaques.

DECIPHERING THE NEUROPATHOLOGICAL PHENOTYPE OF ALZHEIMERS DISEASE: A. Neuritic Plaques: Neuritic plaques, one of the two diagnostic brain lesions observed in Alzheimers original patient, are microscopic foci of extracellular amyloid deposition and associated axonal and dendritic injury, generally found in large numbers in the limbic and association cortices (24). Such plaques contain extracellular deposits of amyloid bprotein (Ab) that occur principally in a filamentous form, i.e., as star-shaped masses of amyloid fibrils. Dystrophic neurites occur both within this amyloid deposit and immediately surrounding it. These neurites are often dilated and tortuous and are marked by ultrastructural abnormalities that include enlarged lysosomes, numerous mitochondria, and paired helical filaments.

Much of the fibrillar Ab found in the neuritic plaques is the species ending at amino acid 42 (Ab42), the slightly longer, more hydrophobic form that is particularly prone to aggregation (70). However, the Ab species ending at amino acid 40 (Ab40), which is normally more abundantly produced by cells than Ab42 (see below), is usually colocalized with Ab42 in the plaque. The cross-sectional diameter of neuritic plaques in microscopic brain sections varies widely from 10 to .120 mm, and the density and degree of compaction of the amyloid fibrils which comprise the extracellular core also shows great variation among plaques. B. The Nature of Diffuse (Preamyloid) Plaques: Many of the plaques found in limbic and association cortices, and virtually all of those in brain regions not clearly implicated in the typical symptomatology of AD (e.g., thalamus, caudate, putamen, cerebellum), showed relatively light, amorphous Ab immunoreactivity that occurred in a finely granular pattern, without a clearly fibrillar, compacted center. Moreover, staining with silver stains highly capable of recognizing dystrophic neurites (e.g., the Bodian method) as well as immunohistochemistry for various neuronal/neuritic cytoskeletal proteins indicated that there was very little or no detectable neuritic dystrophy in most of these amorphous-appearing, nonfibrillar plaques. When it later was determined that the Ab peptides deposited in Alzheimer brain principally ended at either Ab40 or Ab42, it became apparent that peptides ending at Ab42 were the subunits of the material comprising the diffuse plaques, with little or no Ab40 immunoreactivity, in contrast to the mixed (Ab42 plus Ab40) deposits that generally were found in the fibril-rich neuritic plaques (68, 69, 85, 128a). The hypothesis that diffuse plaques represent immature lesions that are precursors to the plaques with surrounding cytopathology arose from two lines of evidence. First, diffuse plaques were the sole form found in those brain regions that largely or entirely lacked neuritic dystrophy, glial changes, and neurofibrillary tangles and were not clearly implicated in the typical clinical symptoms of AD, e.g., cerebellum, striatum, and thalamus. Second, healthy aged humans free of AD or other dementing processes often showed solely diffuse plaques in limbic and association cortices, i.e., in the same regions as Alzheimer patients showed mixtures of diffuse and neuritic plaques. The notion that diffuse plaques could be earlier lesions was later supported by studies of transgenic mice expressing mutant human APP. C. Neurofibrillary Tangles Are Composed of Hyperphosphorylated Tau Proteins

Molecular Pathology of Tau Protein :

On the molecular level tau is understood to perform a specialized function in the regulation of the microtubules, a very central dynamic component of the nerve cytoskeleton. This function is tuned by introducing (kinases) or removing (phosphatases) phosphate groups into the protein at various locations (top panel). The transition into an abnormal form is caused by an excess of phosphates (hyperphosphorylation), imparting an abnormal folding on the protein (middle panel). In this form tau is no longer able to

interact with microtubules, affecting their integrity adversely (bottom panel). Rather it interacts with itself, giving rise to Paired Helical Filament aggregates, and later mature tangles. Altered dynamics of the microtubule network is thought to impair transport processes, which are vital to the sustenance of the nerve cell connections. Failure of this function leads to atrophy of the respective nerve cell processes and electrical isolation of the nerve cell

D. Dystrophic Cortical Neurites Within and Outside Neuritic Plaques: Many of the dilated and tortuous neurites found within and immediately surrounding amyloid plaques contain PHF that are structurally, biochemically, and immunocytochemically indistinguishable from those that comprise the neurofibrillary tangles. In addition, plaques often contain numerous dystrophic neurites that are not immunoreactive for PHF tau. Tau-positive dystrophic neurites are also present in a more widespread distribution in the cortical neuropil outside of the neuritic plaques. The prevalence and density of dystrophic cortical neurites that contain altered forms of tau varies substantially amongAlzheimer cases III. ORIGIN OF AMYLOID b-PROTEIN: CELL BIOLOGY OF b-AMYLOID PRECURSOR PROTEIN Expression and Heterogeneity of APP The purification and partial sequencing of the Ab protein from meningovascular amyloid deposits in AD and Downs syndrome (34, 35) and the subsequent observation that Ab was also the subunit of the plaque amyloid (38, 96, 144) led to the cloning of the gene encoding the b-APP (72). Ab is derived from its large precursor protein by sequential proteolytic cleavages (see sect. IIIB). APP comprises a heterogeneous group of ubiquitously expressed

polypeptides migrating between 110 and 140 kDa on electrophoretic gels (146). This heterogeneity arises both from alternative splicing (yielding 3 major isoforms of 695, 751, and 770 residues) as well as by a variety of posttranslational modifications, including the addition of N- and O-linked sugars, sulfation, and phosphorylation (62, 108, 181, 183). The APP splice forms containing 751 or 770 amino acids are widely expressed in nonneuronal cells throughout the body and also occur in neurons. However, neurons express even higher levels of the 695residue isoform, which occurs at very low abundance in nonneuronal cells (45). The difference between the 751/ 770- and 695-residue forms is the presence in the former of an exon that codes for a 56-amino acid motif that is homologous to the Kunitz-typeof serine protease inhibitors (KPI).

Schematic diagrams of the b-amyloid precursor protein (APP) and its principal metabolic derivatives. Top

diagram depicts the largest of the known APP alternate splice forms, comprising 770 amino acids. Regions of interest are indicated at their correct relative positions. A 17-residue signal peptide occurs at the NH2 terminus (box with vertical lines). Two alternatively spliced exons of 56 and 19 amino acids are inserted at residue 289; the first contains a serine protease inhibitor domain of the Kunitz type (KPI). A single membrane-spanning domain (TM) at amino acids 700723 is indicated by the vertical dotted lines. The amyloid -protein (Ab) fragment includes 28 residues just outside the membrane plus the first 1214 residues of the transmembrane domain. In the middle diagram, the arrow indicates the site (after residue 687; same site as the white dot in the Ab region of APP in the upper diagram) of a constitutive proteolytic cleavage made by protease(s) designated a-secretase that enables secretion of the large, soluble ectodomain of APP (APPs-a) into the medium and retention of the 83-residue COOH-terminal fragment in the membrane. The C83 fragment can undergo cleavage by a protease(s) called g-secretase at residue 711 or residue 713 to release the p3 peptides. The bottom diagram depicts the alternative proteolytic cleavage after residue 671 by a protease(s) called b-secretase that results in the secretion of the slightly truncated APPs-b molecule and the retention of a 99-residue COOH-terminal fragment. The C99 fragment can also undergo cleavage by g-secretase to release the Ab peptides.

B. Trafficking and Proteolytic Processing of APP APP is a single transmembrane polypeptide that is cotranslationally translocated into the endoplasmic reticulum via its signal peptide and then posttranslationally modified (matured) through the secretory pathway. Its acquisition of N- and O-linked sugars occurs rapidly after biosynthesis, and its half-life is relatively brief (;4560 min in most cell types tested) (183). Both during and after the trafficking of APP through the secretory pathway, it can undergo a variety of proteolytic cleavages to release secreted derivatives into vesicle lumens and the extracellular space (Fig. 1). The first proteolytic cleavage identified, that made by an activity designated a-secretase, occurs 12 amino acids NH2-terminal to the single transmembrane domain of APP (28, 156). This processing results in the release of the large soluble ectodomain fragment (a-APPs) into the lumen/extracellular space and retention of an 83-residue COOH-terminal fragment (CTF) in the membrane. Alternatively, some APP molecules not subjected to a-secretase cleavage can be cleaved by an activity designated b-secretase, which principally cuts 16 residues NH2-terminal to the a-cleavage site, generating a slightly smaller ectodomain derivative (b-APPs) (147) and retaining a 99-residue CTF (C99) in the membrane that begins at residue 1 of the Ab region (reviewed in Ref. 143). Until 1992, it was assumed that Ab generation was a pathological event, because the cleavage of the C99 fragment resulting from the so-called g-secretase activity appeared to occur in the middle of the transmembrane domain. It was assumed that this would require the release of C99 from the membrane, for example, as a result of some preexisting membrane injury that allowed access to a soluble protease.

Gamma secretase
Gamma secretase is a multi-subunit protease complex, itself an integral membrane protein, that cleaves single-pass transmembrane proteins at residues within the transmembrane domain. Proteases of this type are known as intramembrane proteases. The most well-known substrate of gamma secretase is amyloid precursor protein, a large integral membrane protein that, when cleaved by both gamma and beta secretase, produces a short 39-42 amino acid peptide called amyloid beta whose abnormally folded fibrillar form is the primary component of amyloid plaques found in the brains of Alzheimer's disease patients. Gamma secretase is also critical in the related processing of the Notch protein.

Subunits and assembly

The gamma secretase complex has not yet been fully characterized[1] but minimally consists of four individual proteins: presenilin, nicastrin, APH-1 (anterior pharynx-defective 1), and PEN-2 (presenilin enhancer 2).[2] Recent evidence suggests that a fifth protein, known as CD147, is a non-essential regulator of the complex whose absence increases activity.[3][4] Presenilin, an aspartyl protease, is the catalytic subunit; mutations in the presenilin gene have been shown to be a major genetic risk factor for Alzheimer's disease.[1] In humans, two forms of presenilin and two forms of APH-1 have been identified in the genome; one of the APH homologs can also be expressed in two isoforms via alternative splicing, leading to at least six different possible gamma secretase complexes that may have tissue- or cell type specificity.[5] The proteins in the gamma secretase complex are heavily modified by proteolysis during assembly and maturation of the complex; a required activation step is in the autocatalytic cleavage of presenilin to N- and C-terminal fragments. Nicastrin's primary role is in maintaining the stability of the assembled complex and regulating intracellular protein trafficking.[6] PEN-2 associates with the complex via binding of a transmembrane domain of presenilin[7] and, among other possible roles, helps to stabilize the complex after presenilin proteolysis has generated the activated N-terminal and C-terminal fragments.[8] APH-1, which is required for proteolytic activity, binds to the complex via a conserved alpha helix interaction motif and aids in initiating assembly of premature components.[9] Recent research has shown that interaction of the gamma secretase complex with the -secretase activating protein facilitates the gamma cleavage of amyloid precursor protein into -amyloid.[10]

Cellular trafficking
The gamma secretase complex is thought to assemble and mature via proteolysis in the early endoplasmic reticulum.[11] The complexes are then transported to the late ER where they interact with and cleave their substrate proteins.[12] Gamma secretase complexes have also been observed localized to the mitochondria, where they may play a role in promoting apoptosis.[13]

Function
Gamma secretase is an internal protease that cleaves within the membrane-spanning domain of its substrate proteins, including amyloid precursor protein (APP) and Notch. Substrate recognition occurs via nicastrin ectodomain binding to the N-terminus of the target, which is then passed via a poorly understood process between the two presenilin fragments to a watercontaining active site at which the catalytic aspartate residue resides. The active site must contain water to carry out hydrolysis within a hydrophobic environment in the interior of the cell membrane, although it is not well understood how water and proton exchange is effected, and as yet no X-ray crystallography structure of gamma secretase is available.[14] Low-resolution electron microscopy reconstructions have allowed the visualization of the hypothesized internal pores of about 2 nanometres.[15]

The gamma secretase complex is unusual among proteases in having a "sloppy" cleavage site at the C-terminal site in amyloid beta generation; gamma secretase can cleave APP in any of multiple sites to generate a peptide from 39 to 42 amino acids long, with A40 the most common isoform and A42 the most susceptible to conformational changes leading to amyloid fibrillogenesis. Certain mutations in both APP and in both types of human presenilin are associated with increased A42 production and the early-onset genetic form of familial Alzheimer's disease.[16] Some evidence has suggested that different forms of the gamma secretase complex are differentially responsible for generating different amyloid beta isoforms;[17] however, very recent research indicates that the C-terminus of amyloid beta is produced by a series of single-residue cleavages by the same isoform, beginning with the generation of A46.[18]

C. Presenilin as a Key Mediator of Notch Signaling:

Hypothetical model of the role of presenilin (PS) in Notch and APP processing based on current information. The diagram shows the predicted 8 TM domain topology of PS, which occurs principally as a cleaved heterodimer. Some Notch and APP molecules form complexes with PS. Two aspartates (D) in TM6 and TM7 of PS are required for the cleavages of Notch and APP within their TM domains, and these may align with the respective sites of cleavage in the two substrates. It is unknown whether PS directly effects these cleavages or whether a still unidentified aspartyl protease (g-secretase) present in the complexes does so. PS-mediated proteolysis of both Notch and APP is preceded by ectodomain shedding due to tumor necrosis factor-a converting enzyme (TACE). Alternatively, APP can undergo ectodomain shedding by b-secretase. Several motifs are depicted in Notch: epidermal growth factor-like repeats (yellow circles), LNG repeats (orange diamonds), a single TM (white box), the RAM23 domain (blue square), a nuclear

localization sequence (red rectangle), and 6 cdc10/ankyrin repeats (green ovals). After the putative intramembranous cleavage mediated by PS, the Notch intracellular domain is released to the nucleus to activate transcription of target genes. APP contains the Ab region (light blue box), which is released into the lumen after sequential cleavages of APP by b-secretase and then g-secretase/PS. The fate of the APP intracellular domain is unknown

C. Inferred Functions of APP and Its Derivatives A number of possible functions have been ascribed to APP holoproteins and/or their major secreted derivative (a-APPs) based on cell culture studies. Soluble a-APPs appear to be capable of acting as an autocrine factor (132) and a neuroprotective and perhaps neuritotrophic factor (98). The fact that the alternatively spliced forms containing 751 and 770 residues contain a 56-residue insert in the middle of the ectodomain encoding a KPI motif (167) has April 2001 ALZHEIMERS DISEASE 747
Downloaded from physrev.physiology.org on October 10, 2011

led to in vitro studies that confirm an ability of these isoforms to inhibit serine proteases such as trypsin and chymotrypsin (154). As mentioned previously, the KPIcontaining isoforms also function as an inhibitor of factor XIa (a serine protease) in the clotting cascade (158). The secreted APP isoforms can confer cell-cell and cell-substrate adhesive properties in culture (e.g., Ref. 140. ) IV. GENETICS OF FAMILIAL ALZHEIMERS DISEASE

Missense Mutations in APP:

b-APP mutations genetically linked to familial Alzheimers disease or related disorders. The sequence within APP that contains the Ab and transmembrane region is expanded and shown by the single-letter amino acid code. The underlined residues represent the Ab142 peptide. The vertical broken lines indicate the location of the transmembrane domain. The bold letters below the line indicate the currently known missense mutations identified in certain patients with familial Alzheimers disease and/or hereditary cerebral hemorrhage with amyloidosis. Three-digit numbers refer to the residue number according to the b-APP770 isoform.
FIG. 2.

C. Missense Mutations in the Presenilins: The Most Common Cause of Autosomal Dominant AD to Date

Nine-transmembrane topology for presenilin. Presenilin is schematically represented. Two aspartate residues in transmembrane domains (TMs) 6 and 7 constituting the catalytic site are indicated. The exon9 mutation (PS1DE9) deletes the indicated region of the protein.
D. The Apolipoprotein E4 Allele is a Major Genetic Risk Factor for Late-Onset AD the discovery that the e4 allele of apolipoprotein E (ApoE) predisposes to AD provided a major genetic risk factor for the disorder in the typical late-onset period (163). Studies initiated by searching for proteins in human cerebrospinal fluid that could bind immobilized Ab peptides on a filter led to the identification of ApoE as such a protein and the recognition that its gene localized to chromosome 19q, in a region previously found to show genetic linkage to AD in some late-onset families (163). Further genetic analyses indicated that the e4 allele of ApoE is overrepresented in subjects with AD compared with the general population and that inheritance of one or two e4 alleles heightens the likelihood of developing AD and makes its mean age of onset earlier than in subjects harboring e2 and or e3 alleles (18, 134). Thus the ApoE4 protein helps precipitate the disorder primarily in subjects in their 60s and 70s. There is also evidence that inheritance of the e2 allele may confer protection against the development of AD (17). Although inheritance of a single e4 allele may increase the likelihood of developing AD in the 60s and 70s, some twoto fivefold and two e4 alleles may increase the risk well above fivefold, it should be emphasized that ApoE4 is a risk factor for, not an invariant cause of, AD. .

Recent developments in Alzheimer's disease therapeutics

Research Strategies
Intervention strategies Researchers in Alzheimer's disease have identified several strategies as possible interventions against amyloid:

Drug Targets in Alzheimers. Currently available treatments for Alzheimer's disease include agents that treat the symptoms of the disease without addressing the biochemical etiology. A second theory regarding the etiology of Alzheimer's is known as the cholinergic hypothesis. A deficit in central cholinergic transmission caused by degeneration of the basal forebrain nuclei is an important pathological and neurochemical feature of AD. A progressive loss of nicotinic receptors over the disease course of AD has also been described, and there is evidence of a role for these receptors in the deficits in memory and cognition.Thus acetylcholinesterase inhibitors that act centrally are of value in treatment. During the neurodegeneration caused by Alzheimer's, an increase in extracellular glutamate is thought to lead to excessive activation of NMDA receptors with consequent intracellular accumulation of Ca2+. This intracellular accumulation of calcium then initiates a cascade of events that results in further neuronal death. NMDA antagonists could potentially protect neurons from glutamate-mediated toxicity without preventing physiological activation of the NMDA receptor. Current Alzheimer's research in medicinal chemistry is aimed at the identification of agents that effect the underlying biochemical causes of Alzheimers. Thus the enzymes gamma-secretase and BACE have become highly desirable targets for specific inhibitors, with the goal of reducing the abnormal processing of APP, and thus the reduction of plaque and tangle formation.

Acetylcholinesterase Inhibitors.

Acetylcholinesterase inhibitors have beneficial effects on cognitive, functional, and behavioural symptoms of Alzheimer's. Tacrine, donepezil, and galantamine selectively inhibit acetylcholinesterase. Galantamine also improves cholinergic neurotransmission by acting as an allosteric ligand at nicotinic acetylcholine receptors to increase presynaptic acetylcholine release and postsynaptic neurotransmission.In addition to the inhibition of acetylcholinesterase, rivastigmine inhibits butyrylcholinesterase, which is about 10% of the total cholinesterase in normal human brains and mainly associated with glial cells. Over the course of Alzheimer's, acetylcholinesterase activity decreases while butyrylcholinesterase activity stabilizes and even increases, probably in relation to glial proliferation; there is also a reported change in the ratio of acetylcholinesterase to butyrylcholinesterase.Butyrylcholinesterase may act as a compensatory mechanism for acetylcholine metabolism and support the potential of butyrylcholinesterase as a suitable target for the treatment of AD.Although donepezil, rivastigmine, and galantamine are part of the same therapeutic class, they differ in their pharmacology and pharmacokinetics.

Memantine. A dysfunction of glutamatergic neurotransmission, manifested as neuronal excitotoxicity, is involved in the etiology of Alzheimer's disease. Targeting the glutamatergic system, specifically NMDA receptors, offers a novel approach to treatment in view of the limited efficacy of existing drugs targeting the cholinergic system. Memantine is a low-affinity voltage-dependent uncompetitive antagonist at glutamatergic NMDA receptors. By binding to the NMDA receptor with a higher affinity than Mg2+ ions, memantine is able to inhibit the prolonged influx of Ca2+ ions which forms the basis of neuronal excitotoxicity. The low-affinity of memantine, however, preserves the physiological function of the receptor as it can still be activated by the relatively high concentrations of glutamate released following depolarisation of the presynaptic neuron.Memantine also acts as an uncompetitive antagonist at the 5HT3 receptor, and as an uncompetetive antagonist at different neuronal nicotinic neuronal receptors (nAChRs) at potencies simular to the NMDA receptor, although it's effects at these loci are not well understood.

Drug Name Aricept (generic name: donepezil) Razadyne, formerly known as Reminyl (generic name:

Molecular Structure

Mechanism of Action acetylcholinesterase inhibitor --Prevents the breakdown of acetylcholine in the brain

Use

For people with mild ,moderate or severe AD

galantamine) acetylcholinesterase inhibitor --Prevents the breakdown of acetylcholine and For people with mild or butyrylcholine (a brain moderate AD chemical similar to acetylcholine) in the brain acetylcholinesterase inhibitors--Prevents the breakdown of acetylcholine and stimulates nicotinic receptors to release more acetylcholine in the brain

Exelon (generic name: rivastigmine)

Razadyne, formerly known as Reminyl (generic name: galantamine)

For people with mild or moderate AD

Memantine -Memantine is marketed under the brands Axura and Akatinol by Merz, Namenda by Forest, Ebixa and Abixa by Lundbeck and Memox by Unipharm

acting on the glutamatergic system by blocking NMDA glutamate receptors -Used to treat moderate to Blocks the toxic severe AD effects associated with excess glutamate and regulates glutamate activation

Note: Cognex (generic name: tacrine) also an acetylcholinesterase inhibitors is not commonly used
because of a number of side effects. Cholinesterase inhibitors are the most widely used drugs for Alzheimer's disease. Cholinesterase inhibitors stop the breakdown of acetylcholine, a chemical in the brain used for memory and other mental functions. These types of medications help increase the levels of acetylcholine. In Alzheimers disease, there is a deficiency in acetlycholine in some areas of the brain, which accounts for some of the symptoms of the disease.

BACE and Gamma-Secretase Inhibitors.

Beta-Secretase inhibitors:These work to block the first cleavage of APP outside of the cell. * Gamma-Secretase inhibitors (e. g. Semagacestat). These work to block the second cleavage of APP in the cell membrane and would then stop the subsequent formation of A and its toxic fragments.

As was outlined above, the aspartyl proteases BACE and gamma secretase are inviting targets for drug discovery. A number of inhibitors are advancing to clinical trials that are transition state analogues of the BACE reaction, which is shown below. As you can see, the cleavage of the bond between a leucine and an aspartate (see above) by BACE generates the amino terminus of APP. Because the aspartyl protease reaction is a hydrolysis, the transition state is tetrahedral, and thus transition state inhibitors must mimic this transition state in order to bind with high affinity.

Transition state inhibitors for aspartyl proteases often include transition state isosteres, the most common of which are statine and hydroxyethylamine. Of course, stereochemistry is a critical component of the drug design process, since only one isomer will have high affinity for the enzyme.

An example of a BACE inhibitor, of which there are now hundreds, appears below. Less is known about gamma secretase, but inhibitors of this enzyme have also been developed, and some have advanced to clinical trials.

Gamma secretase inhibitors are often less complex, but still contain the transition state core:

Selective A42 lowering agents (e. g. Tarenflurbil). These modulate gamma-secretase to reduce A42 production in favor of other (shorter) A versions. * Immunotherapies. These stimulate the host immune system to recognize and attack A or provide antibodies that either prevent plaque deposition or enhance clearance of plaques.

Abeta42 vaccines, monoclonal A antibodies, polyclonal antibodies Immunotherapy targeting the amyloid peptide is a leading approach to disease-modifying treatment [4]. Mechanistically, molecules that bind A peptide in the blood could *draw' the peptide from the brain through the blood-brain barrier, possibly by a receptor-mediated process. Heparin, gelsolin, and other molecules are thought to *sink' or trap A peptide in the blood and, at least in animal models, reduce A accumulation in the brain [5]. Alternatively, such antibodies, which generally penetrate into the brain to a small but definite extent, may promote microglial phagocytosis and clearance of amyloid.
Anti-aggregation agents.These prevent A fragments from aggregating or clear aggregates once they are formed. There is some indication that supplementation of the hormone melatonin may be effective against amyloid.

Drugs in the Pipeline for Alzheimers

A variety of clinical research trials are underway with agents that try either to decrease the amount of A1-42 produced or increase the amount of A1-42 removed. It is hoped that such therapies may slow down the rate of progression of Alzheimer's disease.

Molecular Structure

Mechanism of Action

Clinical Trials

Bapineuzumab- This is a Monoclonal -Elan and Wyeth Antibody

Bapineuzumab is an antibody to the beta-amyloid PIII--Bapineuzumab in Patients With Mild to plaques Moderate Alzheimer's Disease (ApoE4 NonNote: phase II trial, which Carrier) -- Estimated found that bapineuzumab Completion Dec. 2010 failed to improve cognitive function in a test of 234 Alzheimers patients after 18 months of treatment. Gamma secretase inhibitor- These work to block the second cleavage of APP in the cell membrane and would then stop the subsequent formation of amyloid --Semagacestat blocks the enzyme gammasecretase which is responsible for APP proteolysis Phase III --Effect of Gamma-Secretase Inhibition on the Progression of Alzheimer's Disease: LY450139 Versus Placebo Estimated Study Completion Date: June 2012

Semagacestat LY451039 -- Elli Lilly

Dimebon latrepirdine -from Medivation

This drug is an antihistamine used for 25 years in Russia---

Phase III- A Phase 3 Efficacy Study Of Dimebon In Patients With Moderate To Severe Alzheimer's Disease --Estimated Study Completion Date: July 2011

Flurizan (*) Myriad generic name tarenflurbil -enantiomer, or mirror-image molecule, of the non-steroidal anti-inflammatory drug flurbiprofen rember-- Tau Aggregation Inhibitor (First and Second Generation) -TauRx

Lowers toxic A42 production by selectively modulating, but not inhibiting, gamma-secretase activity to shift cleavage of Fails PIII -- See Another amyloid precursor protein Alzheimers Drug Fails in (APP) away from A42 Large-Scale Trials production toward shorter, less toxic peptide fragments. This drug failed a PIII trial. Phase II completed.TRx0014 in Patients With Mild or Moderate Alzheimer's Disease

blocks the formation of Tau oligomers -- ability to dissolve the tau fibers --

Phase II - Ongoing -Open Label Study of TRx0014 in Alzheimer's Disease Completed a Phase IIa study in early Alzheimer's Disease patients and has demonstrated safety and tolerability and showed improvement in executive function Plans for PBT2 to Advance to Phase IIb

PBT2 8Hydroxyquinoline derivative

Note: Image of 8Hydroxyquinoline

targets metal-induced aggregation of A,

Note: Why did Flurizan fail? In the past several years, evidence has mounted that amyloid-beta-42, long considered the culprit in the disease, affects memory-related functions only when it has formed multiprotein conglomerations called oligomers. In the light of this concept, it is possible that Flurizan affects amyloid-beta-42 production in the brain and reduces the formation of insoluble amyloid deposits but has little or no effect on amyloid oligomer levels.

OTHER THERAPIES Since a decrease in muscarinic binding sites in presynaptic cholinergic terminals have been seen in AD, muscarinic receptors are another target for drug development. Talsaclidine (WAL-2014) and cevimeline (AF-102B) are muscarinic receptor agonists that did cause a decline in Ab concentrations. Both entities, however, had undesirable cholinergic side effects, such as increased salivary flow. Cevimeline is now being tested in xerostomia.22 Nicotine receptors are also believed to be important in cholinesterase transmission and may play a role in Ab protein toxicity.23 EVP-6124 is a nicotinic a7 receptor agonist currently undergoing phase 2 trials in mild-to-moderate AD.31 Latripirdine (Dimebon, dimebolin) is a nonselective antihistamine, which is thought to improve mitochondrial function. This helps AD symptoms because mitochondrial dysfunction occurs in early AD and leads to synaptic damage and apoptosis. In the phase 3 CONNECTION study, however, latripirdine showed no benefit in mild-to-moderate AD.22 Nerve growth factor (NGF) may be linked to deactivation of the amyloid pathway and prevention of neurodegeneration. NGF is difficult to administer because of difficulty in crossing the blood-brain barrier. In original trials, NGF was administered as an intracerebroventricular infusion with positive effects on cognition and physiological measurements. However, patients experienced adverse events such as subcortical haemorrhage, weight loss, and pain. Phase 2 trials for innovative NGF delivery devices are planned.22 Histamine H3 antagonists are thought to decrease acetylcholine in the prefontal cortex. Early drug development included compounds GT-2331, ciprofan, and thioperamide, which because of

imidazole-like structures, led to CYP450 inhibition and low CNS permeability. Phase 2 trials of newer compounds, including PF-03654746, GSK239512, MK-0249, and ABT-288, have been completed.32
CONCLUSION: AD is a complex and chronic disease for which the current therapeutic tools offer only a moderate symptomatic relief.A new diagnostic and treatment paradigm is emerging from the very substantial progress in elucidating the functions and dysfunctions of gene products implicated in AD. Currently, the anti-amyloid

strategies are proceeding with the greatest number of candidate drugs. Numerous candidate disease-modifying therapies that target the underlying pathogenic mechanisms of AD are currently in clinical trials. While it is not possible to predict the success of any individual program, one or more are likely to prove effective. Indeed, it seems reasonable to predict that in the not-too-distant future, a synergistic combination of agents will have the capacity to alter the neurodegenerative cascade and reduce the global impact of this devastating disease.