European Journal of Neurology 2011, 18: 59–68 doi:10.1111/j.1468-1331.2010.03092.

Efficacy and safety of Cerebrolysin in moderate to moderately

severe AlzheimerÕs disease: results of a randomized, double-blind,
controlled trial investigating three dosages of Cerebrolysin
X. A. Alvareza, R. Cacabelosa, C. Sampedroa, M. Aleixandreb, C. Linaresc, E. Granizoc,
E. Dopplerd and H. Moesslerd
a
EuroEspes Biomedical Research Centre, Santa Maria de Babio, 15166 Bergondo, La Coruna; bFaculty of Psychology, Granada University,
Granada; cMemory Clinic, Malaga, Spain; and dEVER Neuro Pharma, formerly registered as EBEWE Neuro Pharma, Oberburgau 3,
Austria

Keywords: Background: Cerebrolysin is a neuropeptide preparation mimicking the effects of

AlzheimerÕs disease,
Cerebrolysin, randomized
controlled trial
Received 3 July 2009
Accepted 9 March 2010
neurotrophic factors. This subgroup analysis assessed safety and efficacy of Cere-
brolysin in patients with moderate to moderately severe AlzheimerÕs disease (AD)
(ITT data set: N = 133; MMSE: 14–20) included in a dose-finding study (ITT data
set: N = 251; MMSE: 14–25). Results of the mild AD subgroup (ITT data set:
N = 118; MMSE: 21–25) are also presented.
Methods: Patients with AD received 100 ml IV infusions of Cerebrolysin (10, 30 or
60 ml diluted in saline; N = 32, 34 and 35, respectively) or placebo (saline; N = 32)
over twelve weeks (5 days per week for 4 weeks and 2 days per week for another
8 weeks). Primary efficacy criteria ADAS-cog+ (AlzheimerÕs Disease Assessment
Scale Cognitive Subpart Modified) and CIBIC+ (Clinical Interview-based Impression
of Change with Caregiver Input) were assessed 24 weeks after baseline.
Results: At week 24, Cerebrolysin improved the global clinical function significantly
with all three dosages and induced significant improvements in cognition, initiation of
activities of daily living (ADL) and neuropsychiatric symptoms at 10-, 30- and 60-ml
doses, respectively. Treatment effects on total ADL and other secondary parameters
(MMSE, Trail-making test) were not significant. Cerebrolysin was safe and well tol-
erated.
Conclusions: These results demonstrate the efficacy of Cerebrolysin in moderate to
moderately severe AD, showing dose-specific effects similar to those reported for
patients with mild to moderate AD. The benefits of Cerebrolysin in advanced AD need
to be confirmed in larger trials.

modifying drugs [1,3]. Amyloid-based therapies and

Introduction
Cholinesterase inhibitors and memantine provide
symptomatic relief to patients with AlzheimerÕs disease
(AD), with no evidence of disease modification [1]. Both
classes of compounds have positive effects on cognition
and global clinical outcome, being less consistent with
their benefits on behaviour and quality of life [2,3].
Priorities of current AD therapeutic research are to
optimize symptomatic treatment, especially for moder-
ately severe disease stages, and to develop disease-
Correspondence: X. Antón Alvarez, MD, PhD, EuroEspes
Biomedical Research Centre, Santa Maria de Babio, 15166 Bergondo,
La Coruna, Spain (tel.: +34 981 780505, fax +34 981 780511,
e-mail: xantonal@yahoo.es).
neurotrophic treatment are amongst the most promis-
ing alternatives for disease modification in AD [4,5]. As
the number of trials in moderate to severe AD is quite
limited, the evaluation of new drugs in this disease stage
is highly recommendable [6].
Cerebrolysin is a neuropeptide preparation free of
proteins, lipids and antigenic properties that contains
215.2 mg of low molecular weight peptides and free
amino acids per millilitre. Cerebrolysin displays
neurotrophic activity on dorsal root ganglia neurons
[7] and rescues medial septal cholinergic neurons in
a model of fimbria fornix transection after
peripheral injection [8]. Neurotrophic-neuroprotective
and procognitive effects of Cerebrolysin were also

 2010 The Author(s)

European Journal of Neurology  2010 EFNS 59
60 X. A. Alvarez et al.

demonstrated in different animal models of AD [9–11]. Ethical aspects

Recent studies showed that Cerebrolysin reduces the
This clinical study was performed in compliance with
production of amyloid-b in transgenic mice [12] and
Good Clinical Practice and the principles of the
promotes neurogenesis [13,14].
Declaration of Helsinki (1964) and subsequent revi-
Several randomized controlled clinical trials (RCTs)
sions. Ethical approval for the study was granted by the
have evaluated the efficacy of Cerebrolysin in mild to
Comité Ético de Investigación Clı́nica de Galicia. The
moderate AD with positive results [15–20]. In a recent
trial was registered at the Spanish Health Authorities
RCT performed with three doses of Cerebrolysin in
registry (99–0120). Informed consent was given in
mild to moderate AD, we found that in comparison
writing by all patients and their caregivers. Co-authors
with placebo Cerebrolysin improved global function,
HM and ED are employees of EBEWE Pharma. Both
cognition and neuropsychiatric symptoms in a dose-
have no ownership in the company, and their com-
dependent manner [15]. Here we report for the first time
pensation is not linked to the outcome of research
on the safety and efficacy of three dosages of Cere-
projects. The EuroEspes Biomedical Centre and the
brolysin in the subgroup of patients with moderate
authors did not receive from EBEWE Pharma any
[clinician’s interview-based impression of severity
financial support for activities other than those directly
(CIBIS)+ 3–4)] to moderately severe (CIBIS+ 5) AD
related to the conduction and communication of
enrolled in a larger RCT [15]. Although it was not
research studies. No further commercial or other asso-
included in the original statistical plan and the study was
ciations to disclose. This study was sponsored by
not powered to show differences between subgroups,
EBEWE Pharma. Both the sponsor and the authors
data of the subgroup of patients with mild AD (MMSE:
acted as guarantors of the study and had full access to
21–25) were analysed and the results are presented.
the data. The sponsor was involved in development of
study design, collection and interpretation of the data,
Methods and patients in the writing of the report and in the decision to submit
the manuscript for publication.
Study design

This 24-week, randomized, double-blind, placebo-con- Efficacy measures

trolled study was performed at one study site in Spain.
Primary efficacy measures were the AlzheimerÕs Disease
Patients were randomly allocated to 10-, 30- or 60-ml
Assessment Scale Cognitive Subpart Modified (ADAS-
Cerebrolysin or placebo in a 1:1:1:1 ratio. Patients
cog+) score [25] change from baseline to Week 24 and
received intravenous (IV) infusions of Cerebrolysin or
the CIBIC+ score [26] at Week 24. Secondary efficacy
placebo 5 days per week for 4 weeks and on 2 days per
measures were changes from baseline to Week 4, 12 and
week in the following 8 weeks. Patient evaluations were
24 in MMSE, ADAS-cog [27], Neuropsychiatric
performed at screening and baseline, during (Week 4)
Inventory (NPI) [28], Disability Assessment in
and after (Week 12) active treatment and 12 weeks
Dementia (DAD) [29] and Trail-making Test (Trails-A)
thereafter (Week 24).
[30] scores. Responder rates were assessed for ADAS-
cog+ (responder: improvement of ‡4 points relative to
Patient population baseline) and CIBIC+ (responder: score £3; corre-
sponding to improvement).
Male and female outpatients of >50 years were eligible
for study participation if they had a diagnosis of
probable AD [21]. Inclusion criteria included a Mini- Safety measures
Mental State Examination (MMSE) [22] score of 14–25
Adverse events (AEs) and vital signs were monitored
(patients with a MMSE score at baseline of 14–20, both
during the study. Laboratory parameters were assessed
inclusive, were selected for the subgroup analysis), a
at baseline, Week 12 and Week 24. Physical and neu-
Modified Hachinski Ischaemia Scale [23] score of £4, a
rological examinations were evaluated at baseline,
Hamilton Depression Scale [24] score of £15, a com-
Week 4, 12 and 24.
puter tomography (CT) or magnetic resonance imaging
(MRI) consistent with the diagnosis of probable AD,
good general health without clinically significant Statistical analysis
laboratory abnormalities or other diseases expected to
Efficacy analyses are based on the Intention-to-Treat
interfere with the study. Exclusion criteria as specified
(ITT) patient population, which includes all rando-
in the previous publication [15] were the usual for this
mized patients who had a baseline MMSE score of £20,
kind of clinical trials.

 2010 The Author(s)

European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
 Cerebrolysin in moderate to moderately severe AlzheimerÕs disease 61

received at least one dose of study medication and had
baseline and at least one post-baseline assessment of
both primary end-points. In case of missing data, the
last-observation-carried-forward (LOCF) method was
applied. Comparability of the groups at baseline was
assessed using descriptive statistics and appropriate
parametric and non-parametric statistical tests. Efficacy
variables were analysed using two-tailed statistics.
Analyses were considered significant if a probability
level of P < 0.05 was achieved. CIBIC+ score was
analysed by Cochran-Mantel-Haenszel (CMH); ADAS-
cog+ and secondary outcome measures were subjected
to analysis of covariance (ANCOVA) using baseline score
as a covariate. Responder rates were analysed using
logistic regression, and odds ratios for achieving a
response to treatment and the 95% CI were estimated.
Exactly the same analyses were conducted in the sub-
group of patients with baseline MMSE score ‡21. For
safety analysis, treatment groups were compared with
respect to incidence rates of AEs, changes in vital signs,
laboratory abnormalities, physical and neurological
examination findings and weight changes.
Results
Patient disposition
Of 279 patients randomized, 251 patients were included
in the total ITT analysis set and of these 133 patients
qualified for subgroup analysis (ITT:MMSE £ 20).
Patient numbers and reasons for discontinuation are
given in Fig. 1. The mild AD subgroup was integrated
by 118 patients (ITT:MMSE 21–25).
Demographic data and baseline disease characteristics
No significant group differences were observed at
baseline (Table 1). Mean disease duration at baseline
was 4.6 ± 0.23 years. Treatment groups were com-
parable for cognitive performance and global clinical
impression and were in accordance with a population
suffering from moderate to moderately severe AD. The
use of concomitant medication was similar in all
treatment groups. The same applies for patients with
mild AD (Table 2).
Efficacy
Cerebrolysin 10-ml, but not 30- and 60-ml, was effective
in improving cognitive performance as assessed by
ADAS-cog+ with a significant treatment difference
compared to placebo at Week 24 (Table 3, Fig. 2). This
improvement was confirmed by a responder rate of
37.5% versus 12.5% in the placebo group. The odds
ratios for achieving response in ADAS-cog+ were
significant with 10-ml (4.20; 95% CI: 1.18/14.93;
P = 0.026) and 30-ml doses (3.82; 95% CI: 1.08/13.48;
P = 0.037), but not with the dose of 60-ml (2.80; 95%

Randomized
N = 279

Cerebrolysin 10 ml Cerebrolysin 30 ml Cerebrolysin 60 ml Placebo

N = 69 N = 70 N = 71 N = 69

Received no medication (N = 5) Received no medication (N = 1) No post-baseline data (N = 3) Received no medication (N = 4)

No post-baseline data (N = 4) No post-baseline data (N = 4) No post-baseline data (N = 7)

ITT Population ITT Population ITT Population ITT Population

N = 60 N = 65 N = 68 N = 58

ITT: MMSE ≤ 20 ITT Population

N = 133 N = 251

Cerebrolysin 10 ml Cerebrolysin 30 ml Cerebrolysin 60 ml Placebo

N = 32 N = 34 N = 35 N = 32

Total discontinued Total discontinued Total discontinued Total discontinued

N=1 N=3 N=2 N=4

Adverse event (N = 1) Noncompliance (N = 1) Noncompliance (N = 1) Noncompliance (N = 1)

Consent withdrawn (N = 1) Consent withdrawn (N = 1) Consent withdrawn (N = 2)
Other reasons (N = 1) Other reasons (N = 1)

Completed study Completed study Completed study Completed study

N = 31 N = 31 N = 33 N = 28

Figure 1 Enrolment and disposition of all patients participating in the clinical study (ITT data set) and of patients having an MMSE score
of £20 at baseline (ITT:MMSE £ 20 data set). ITT, intention to treat; MMSE, Mini-Mental State Examination.

 2010 The Author(s)

European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
62 X. A. Alvarez et al.

Table 1 Selected demographic data and

Cerebrolysin baseline disease characteristics
10 ml 30 ml 60 ml Placebo

(n = 32) (n = 34) (n = 35) (n = 32)

Gender
Male 5 (15.6) 7 (20.6) 9 (25.7) 8 (25.0)
Female 27 (84.4) 27 (79.4) 26 (74.3) 24 (75.0)
Age (years) 72.4 ± 1.98 75.1 ± 1.54 75.3 ± 1.25 77.0 ± 1.63
Disease duration (years) 4.3 ± 0.41 4.2 ± 0.39 4.3 ± 0.47 5.7 ± 0.53
MMSE
Mean ± SE 16.4 ± 0.4 17.0 ± 0.3 16.3 ± 0.3 16.8 ± 0.4
ADAS-cog+
Mean ± SE 49.7 ± 2.4 43.5 ± 2.0 45.1 ± 2.0 44.4 ± 2.2
CIBIS+
Mildly ill (3) 1 (3.1) 1 (2.9) 3 (8.6) 1 (3.1)
Moderately ill (4) 20 (62.5) 27 (79.4) 24 (68.6) 20 (62.5)
Markedly ill (5) 11 (34.4) 6 (17.6) 8 (22.9) 11 (34.4)

Values are n (%) for gender and CIBIS+ score and mean ± standard error for age and disease
duration; ITT:MMSE £ 20 data set.

Table 2 Selected demographic data and

Cerebrolysin baseline disease characteristics
10 ml 30 ml 60 ml Placebo

(n = 28) (n = 31) (n = 33) (n = 26)

Gender
Male 12 (42.9) 9 (29.0) 11 (33.3) 12 (46.2)
Female 16 (57.1) 22 (71.0) 22 (66.7) 14 (53.8)
Age (years) 72.0 ± 1.59 71.5 ± 1.44 73.9 ± 1.25 70.1 ± 1.86
Disease duration (years) 4.4 ± 0.66 3.5 ± 0.40 3.3 ± 0.37 4.0 ± 0.49
MMSE
Mean ± SE 23.4 ± 0.3 22.7 ± 0.2 23.2 ± 0.2 23.4 ± 0.3
Range 21–25 21–25 21–25 21–25
ADAS-cog+
Mean ± SE 25.0 ± 1.8 28.3 ± 1.7 25.1 ± 1.4 22.6 ± 1.4
Range 11–49 12–50 10–47 12–35
CIBIS+
Mildly ill (3) 18 (64.3) 19 (61.3) 23 (69.7) 16 (61.5)
Moderately ill (4) 10 (35.7) 12 (38.7) 10 (30.3) 10 (38.5)
Markedly ill (5) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

Values are n (%) for gender and CIBIS+ score and mean ± standard error for age and disease
duration; ITT:MMSE 21–25 data set.

CI: 0.78/10.06; P = 0.114). In the subgroup of patients
with mild AD, Cerebrolysin enhanced the cognitive
performance with respect to baseline at all doses tested,
but no significant treatment effects were demonstrated
(Table 4).
In the CIBIC+, all Cerebrolysin dosages improved
global clinical function significantly in comparison with
placebo. Best treatment effects were obtained with
10-ml Cerebrolysin, followed by 30-ml and 60-ml
dosages. CIBIC+ responder analysis confirmed results
of CIBIC+ score analysis (Table 3). Odds ratios for the
proportion of patients achieving a CIBIC+ response
were significant for all Cerebrolysin doses (Table 3).
Cerebrolysin also improved global functioning sig-
nificantly with all doses in mild AD (Table 4), but the
odds ratios for achieving a CIBIC+ response were
clearly lower than in moderate to moderately severe
AD, which is consistent with the different rate of
CIBIC+ responders observed in both subgroups for
patients on placebo (Tables 3 and 4).
Analysis of the secondary efficacy criteria provided
supportive evidence for the efficacy of Cerebrolysin. In
activities of daily living as assessed by DAD, Cere-
brolysin-treated patients performed better than those
on placebo but failed to reach the level of statistical
significance (Table 3). Analyses of DAD subscores

 2010 The Author(s)

European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
 Cerebrolysin in moderate to moderately severe AlzheimerÕs disease 63

Table 3 Summary of efficacy statistics at Week 24 for the ITT:MMSE £ 20 population

Baseline score LS mean change ± SE Treatment differencea 95% CI P-value

ADAS-cog+
Placebo 44.36 4.538 ± 1.853
10-ml Cere 49.73 )1.838 ± 1.876 )6.376 )12.665/)0.087 0.046
30-ml Cere 43.48 0.007 ± 1.802 )4.531 )10.659/1.596 0.195
60-ml Cere 45.09 1.672 ± 1.770 )2.866 )8.950/3.219 0.541
Disability Assessment in Dementia
Placebo 52.59 )6.20 ± 3.00
10-ml Cere 50.42 )3.26 ± 3.02 2.94 )5.45/11.33 0.488
30-ml Cere 62.47 1.46 ± 2.93 7.65 )0.69/16.00 0.072
60-ml Cere 59.15 )5.08 ± 2.87 1.12 )7.12/9.36 0.789
NPI
Placebo 13.6 2.5 ± 2.1
10-ml Cere 18.2 )0.9 ± 2.2 )3.4 )9.4/2.6 0.264
30-ml Cere 10.8 )3.1 ± 2.1 )5.6 )11.5/0.3 0.063
60-ml Cere 13.5 )3.7 ± 2.0 )6.2 )12.0/)0.3 0.039

CIBIC+ Score ± SD Responders (%)b Odds ratioc 95% CI P-value

Placebo 5.06 ± 0.34 9.4

10-ml Cere 3.34 ± 1.82 59.4 14.13 3.55/56.28 0.0002
30-ml Cere 3.41 ± 0.44 55.9 12.24 3.12/48.09 0.0003
60-ml Cere 3.66 ± 1.49 45.7 8.14 2.08/31.78 0.0026
a
For ADAS-cog+ and NPI negative treatment differences indicate a favourable effect of Cerebrolysin compared to placebo; bCIBIC+ responders
are defined as having a score £3; cOdds ratios are for Cerebrolysin versus placebo. N = 32 for 10-ml Cerebrolysin (Cere), N = 34 for 30-ml Cere,
N = 35 for 60-ml Cere, N = 32 for placebo.

showed at all study visits significant superiority of the Trails-A, Cerebrolysin-treated patients showed
30-ml Cerebrolysin over placebo in ÔInitiationÕ with the numerically but not statistically better results than
highest estimated treatment difference of 11.65 points patients on placebo. Results obtained in the subgroup
(95% CI: 2.10/21.21; P = 0.017) at Week 24 (Table 5). of patients with mild AD are in line with those observed
Cerebrolysin was descriptively superior to placebo in in moderate to moderately severe AD, although no
improving neuropsychiatric disturbances as measured significant treatment effects were found. Patients trea-
by NPI, but significant treatment differences were only ted with Cerebrolysin showed descriptively better per-
observed with the 60-ml dosage (Table 3, Fig. 3). For formance in activities of daily living than those on
the other secondary outcome measures, the MMSE and placebo (Table 4); and particularly in instrumental
ADAS–cog+ score LS mean change from baseline

–5 Placebo
P=0.011 Cerebrolysin 10 ml
–4 Cerebrolysin 30 ml
P=0.048 Cerebrolysin 60 ml
–3
P=0.046
–2

–1

0
Figure 2 Time course of the ADAS-
cog+: LS mean change from baseline. 1
ITT:MMSE £ 20 analysis, n = 32 for
2
10-ml, n = 34 for 30-ml, n = 35 for
60-ml Cerebrolysin and n = 32 for 3
placebo. Negative score differences
4
indicate improvement. Exact P-values
Active treatment
for comparison to placebo are given for 5
10-ml (Week 12, Week 24) and 30-ml 0 4 8 12 16 20 24
(Week 4) Cerebrolysin dose groups. Study week

 2010 The Author(s)

European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
64 X. A. Alvarez et al.

Table 4 Summary of efficacy statistics at Week 24 for the ITT:MMSE 21-25 population

Baseline score LS mean change ± SE Treatment differencea 95% CI P-value

ADAS-cog+
Placebo 22.62 )0.753 ± 1.382
10-ml Cere 24.96 )1.840 ± 1.317 )1.087 )5.60/3.432 0.888
30-ml Cere 28.27 )2.557 ± 1.271 )1.804 )6.316/2.708 0.650
60-ml Cere 25.12 )1.994 ± 1.213 )1.241 )5.597/3.115 0.831
Disability Assessment in Dementia
Placebo 79.01 0.06 ± 2.05
10-ml Cere 79.19 1.97 ± 1.98 1.90 )3.74/7.55 0.506
30-ml Cere 83.41 1.04 ± 1.89 0.98 )4.55/6.50 0.727
60-ml Cere 76.38 1.18 ± 1.83 1.12 )4.33/6.56 0.686
NPI
Placebo 12.5 )1.9 ± 1.6
10-ml Cere 12.7 )2.4 ± 1.6 )0.6 )5.1/3.9 0.805
30-ml Cere 10.1 )1.5 ± 1.5 0.3 )4.1/4.8 0.876
60-ml Cere 12.8 )6.0 ± 1.5 )4.1 )8.4/0.2 0.064

CIBIC+ Score ± SD Responders (%)b Odds ratioc 95% CI P-value

Placebo 4.23 ± 1.31 34.6

10-ml Cere 2.89 ± 1.42 71.4 4.72 1.49/14.93 0.008
30-ml Cere 3.06 ± 1.18 64.5 3.43 1.15/10.24 0.027
60-ml Cere 2.94 ± 0.83 72.7 5.04 1.65/15.34 0.004
a
For ADAS-cog+ and NPI negative treatment differences indicate a favourable effect of Cerebrolysin compared to placebo; bCIBIC+ responders
are defined as having a score £3; cOdds ratios are for Cerebrolysin versus placebo. N = 28 for 10-ml Cerebrolysin (Cere), N = 31 for 30-ml Cere,
N = 33 for 60-ml Cere, N = 26 for placebo.

Table 5 Disability Assessment in Dementia

Baseline Week 4 Week 12 Week 24 (DAD) subscores changes from baseline for
the ITT:MMSE £ 20 population
Basic activities
Placebo 77.02 ± 4.01 )4.13 ± 2.37 )4.76 ± 3.18 )7.96 ± 3.98
10-ml Cere 72.61 ± 5.13 0.08 ± 2.38 )0.29 ± 3.20 )5.81 ± 4.00
30-ml Cere 82.50 ± 3.83 2.11 ± 2.30 2.93 ± 3.10 0.13 ± 3.88
60-ml Cere 79.66 ± 4.25 )2.83 ± 2.26 )4.07 ± 3.04 )5.97 ± 3.81
Instrumental activities
Placebo 34.39 ± 5.47 )2.43 ± 2.06 )2.38 ± 2.22 )5.06 ± 2.81
10-ml Cere 33.18 ± 4.75 0.23 ± 2.06 0.58 ± 2.22 )1.64 ± 2.81
30-ml Cere 47.19 ± 4.69 1.42 ± 2.01 3.29 ± 2.16 2.59 ± 2.73
60-ml Cere 43.88 ± 4.15 0.32 ± 1.96 )1.87 ± 2.12 )4.41 ± 2.68
Initiation
Placebo 57.43 ± 4.49 )4.56 ± 2.46 )3.63 ± 2.82 )7.97 ± 3.45
10-ml Cere 54.32 ± 4.77 1.07 ± 2.48 1.49 ± 2.83 )2.89 ± 3.47
30-ml Cere 66.01 ± 4.19 4.05 ± 2.40 6.41 ± 2.75 3.68 ± 3.36
60-ml Cere 63.25 ± 4.44 )2.86 ± 2.36 )5.01 ± 2.70 )7.37 ± 3.30
Planning and Organization
Placebo 42.97 ± 4.83 )2.49 ± 2.16 )2.58 ± 2.62 )6.19 ± 3.45
10-ml Cere 41.29 ± 5.21 0.15 ± 2.16 0.91 ± 2.63 )2.86 ± 3.46
30-ml Cere 50.08 ± 4.78 2.66 ± 2.10 3.51 ± 2.55 2.43 ± 3.35
60-ml Cere 48.44 ± 4.15 )0.04 ± 2.06 )1.60 ± 2.51 )3.75 ± 3.30
Effective performance
Placebo 55.21 ± 4.68 )2.36 ± 2.20 )3.68 ± 2.57 )5.02 ± 3.12
10-ml Cere 53.68 ± 4.44 )0.74 ± 2.20 )1.21 ± 2.58 )4.32 ± 3.13
30-ml Cere 68.09 ± 3.84 )0.15 ± 2.15 0.35 ± 2.51 )0.54 ± 3.05
60-ml Cere 63.17 ± 3.92 )0.03 ± 2.09 )1.65 ± 2.45 )3.91 ± 2.97

Values are mean ± SE for baseline and LS mean ± SE for Week 4, 12 and 24. Negative DAD
scores indicate deterioration. N = 32 for 10-ml Cerebrolysin (Cere), N = 34 for 30-ml Cere,
N = 35 for 60-ml Cere, N = 32 for placebo.

 2010 The Author(s)

European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
 Cerebrolysin in moderate to moderately severe AlzheimerÕs disease 65

Placebo
–6 Cerebrolysin 10 ml
P<0.05

NPI Score LS mean change from baseline

Cerebrolysin 30 ml
–5 Cerebrolysin 60 ml
P<0.05
–4

–3
Figure 3 Time course of the NPI: LS
–2
mean change from baseline.
ITT:MMSE £ 20 analysis, n = 32 for –1
10-ml, n = 34 for 30-ml, n = 35 for
0
60-ml Cerebrolysin and n = 32 for
placebo. Negative score differences 1
indicate improvement. Exact P-values for
2
comparison to placebo are given for the
Active treatment
Cerebrolysin 30 ml (Week 12) and 3
Cerebrolysin 60 ml (Week 24) dose 0 4 8 12 16 20 24
groups. Study week

activities, effective performance and initiation subscores adverse events did not show group differences. At least
with the 10-ml dose (Table 6). Cerebrolysin 60-ml one AE was experienced by 56.3% of patients on 10-ml
induced a borderline significant improvement in beha- Cerebrolysin, 47.1% of patients on 30-ml, 62.9% of
viour when compared to placebo ()4.1; 95% CI: )8.4/ patients on 60-ml and 62.5% of patients on placebo.
0.2; P = 0.064) (Table 4). The Costart Body Systems with the highest incidence
rate were ÔNervous SystemÕ with 34 events, ÔBody as a
WholeÕ with 23 events and ÔUrogenital SystemÕ with 22
Safety
events. The most common AEs with an incidence rate
All 133 patients of the ITT:MMSE £ 20 subgroup were of >10% were depression and fever, each affecting
included in the safety population. The incidence of 12.5% of patients in the 10-ml group, and urinary tract

Table 6 Disability Assessment in Dementia

(DAD) subscores changes from baseline for Baseline Week 4 Week 12 Week 24
the ITT:MMSE 21-25 population
Basic activities
Placebo 88.46 ± 3.83 0.04 ± 0.88 0.65 ± 1.32 )0.52 ± 2.12
10-ml Cere 91.81 ± 2.83 0.69 ± 0.85 1.13 ± 1.27 0.30 ± 2.04
30-ml Cere 95.05 ± 2.72 0.88 ± 0.81 0.03 ± 1.21 )0.08 ± 1.95
60-ml Cere 88.50 ± 2.92 0.20 ± 0.78 )0.02 ± 1.17 )1.52 ± 1.88
Instrumental activities
Placebo 71.62 ± 5.65 1.43 ± 1.63 1.95 ± 2.31 0.56 ± 2.70
10-ml Cere 69.70 ± 5.65 3.20 ± 1.57 5.38 ± 2.22 3.21 ± 2.61
30-ml Cere 74.33 ± 4.99 2.18 ± 1.50 3.07 ± 2.12 2.18 ± 2.48
60-ml Cere 66.98 ± 4.51 2.02 ± 1.45 3.44 ± 2.05 3.03 ± 2.41
Initiation
Placebo 78.53 ± 4.95 0.72 ± 1.98 2.56 ± 2.00 1.61 ± 2.52
10-ml Cere 78.55 ± 4.27 2.89 ± 1.91 4.25 ± 1.93 4.47 ± 2.43
30-ml Cere 84.41 ± 3.56 2.03 ± 1.82 1.84 ± 1.85 1.59 ± 2.32
60-ml Cere 76.94 ± 3.80 0.56 ± 1.76 2.48 ± 1.78 2.29 ± 2.24
Planning and Organization
Placebo 73.20 ± 5.80 1.60 ± 1.58 1.28 ± 2.00 )0.39 ± 2.43
10-ml Cere 74.29 ± 5.52 0.75 ± 1.52 1.71 ± 1.93 )0.53 ± 2.34
30-ml Cere 79.58 ± 4.34 )0.17 ± 1.46 0.09 ± 1.85 0.00 ± 2.24
60-ml Cere 66.05 ± 4.72 2.50 ± 1.41 3.05 ± 1.79 1.67 ± 2.18
Effective performance
Placebo 83.26 ± 4.20 0.32 ± 1.12 0.58 ± 1.65 )0.91 ± 2.04
10-ml Cere 83.02 ± 3.90 2.43 ± 1.08 4.25 ± 1.59 1.60 ± 1.97
30-ml Cere 85.32 ± 3.68 2.73 ± 1.03 2.68 ± 1.51 1.50 ± 1.87
60-ml Cere 82.95 ± 3.61 1.24 ± 1.00 1.30 ± 1.46 )0.01 ± 1.81

Values are mean ± SE for baseline and LS mean ± SE for Week 4, 12 and 24. Negative DAD
scores indicate deterioration. N = 28 for 10-ml Cerebrolysin (Cere), N = 31 for 30-ml Cere,
N = 33 for 60-ml Cere, N = 26 for placebo.

 2010 The Author(s)

European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
66 X. A. Alvarez et al.
infection with 12.5% in the 10-ml group, 20.0% in the
60-ml group and 25.0% in the placebo group. Four
patients reported serious adverse events, two in the
10-ml group and one each in the 30-ml and placebo
groups. None of these cases was causally related to the
study drug. No case of death was reported in this
population. Safety evaluation of Cerebrolysin did not
show any safety issue when used in doses up to 60 ml in
patients with moderate to moderately severe AD.
Discussion
Results of this study demonstrate significant improve-
ments in cognitive performance and global clinical
function in patients with moderate to moderately severe
AD after treatment with 10-ml Cerebrolysin. Results of
behaviour and activities of daily living were descrip-
tively but not statistically in favour of 10-ml Cere-
brolysin when compared to placebo (Table 3). Similar
positive trends were observed in mild AD with 10-ml
Cerebrolysin, which significantly improved global
functioning only (Table 4).
Almost similar treatment effects were observed with
the 30-ml Cerebrolysin dose, enhancing global clinical
function and the probability of achieving an ADAS-
cog+ response significantly with respect to placebo.
Marginal significant improvements were reported for
behaviour and activities of daily living (Tables 3 and 4,
Fig. 3). A significant treatment effect of 30-ml Cere-
brolysin was observed in the DAD subscore ÔinitiationÕ,
which indicates that patients are more active and prone
to perform activities of daily living. Altogether, these
results suggest that 30-ml Cerebrolysin might also be
effective for the treatment of patients with moderate to
moderately severe AD. In the subgroup of patients with
mild AD, Cerebrolysin 30 ml improved the global
clinical function significantly and induced descriptively
higher effects on cognition and activities of daily living
when compared to placebo (Table 4).
Treatment with 60-ml Cerebrolysin resulted in sig-
nificant improvements in global function and neu-
ropsychiatric symptoms, with no significant effects on
cognitive performance and activities of daily living.
Mild favourable treatment differences observed for
cognition and activities of daily living, together with the
significant reduction of behavioural disturbances might
account for the significant results of this Cerebrolysin
dose in the global clinical evaluation. Almost similar
results were observed with this dose of Cerebrolysin in
patients with mild AD (Table 4).
In summary, efficacy results of this study indicate a
somewhat dose-specific response to Cerebrolysin with
dosages of 10–30 ml to improve cognition and the
initiation of daily living activities and dosages of
European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
30–60 ml to improve behaviour in patients with mod-
erate to moderately severe AD. Basically the same
dissociated response was observed with low and high
doses of Cerebrolysin in mild AD. Global clinical
function was improved by all Cerebrolysin dosages. The
improvements in CIBIC+ evaluations, even besides
significant effects in particular domains, seem to reflect
the positive influence of Cerebrolysin on some key
clinical aspects frequently observed/reported by clin-
icians and caregivers like alertness, general activity and
motivation. According to the clinical interview-based
impression, after treatment with Cerebrolysin, patients
were more reactive and communicative, showed a
higher involvement in social interactions and daily
activities, and appeared more tranquil, self-confident
and with an enhanced well-being feeling. These
observations are consistent with significant and/or
relative improvements detected in cognition and activ-
ities of daily living (initiation, effective performance and
instrumental activities), as well as with significant
reductions in NPI symptoms like irritability, agitation,
depression and apathy (data not shown).
According to the present results, cognitive benefits of
Cerebrolysin are more pronounced in moderate to
moderately severe than in mild patients. This difference
seems to be mainly owing to the cognitive decline
exhibited by moderate to moderately severe patients on
placebo, which was absent in mild AD. Similar
observations were reported for 30-ml Cerebrolysin [18]
and for rivastigmine [31]. The effect size of Cerebrolysin
in the cognitive domain in moderate to moderately
severe AD is comparable to that reported for choli-
nesterase inhibitors and memantine [2,3,32]. Current
and previous data [15–18] show that Cerebrolysin
improves global function and cognition to the same
extent as cholinesterase inhibitors [3,33–35].
The positive effects of Cerebrolysin were sub-
stantially similar at the end of the treatment period
(Week 12) and twelve weeks later (Week 24). This is in
agreement with reports of persisting efficacy for several
months after stopping Cerebrolysin treatment
[15,17,18] and is in contrast to the loss of efficacy of
cholinesterase inhibitors within 6 weeks [36]. Long-term
cognitive effects of Cerebrolysin are also in good
agreement with a putative neurotrophic mode of action
and with its long-lasting influence on behaviour, den-
dritic arbourization and synaptogenesis [10,11]. The
reduction of brain amyloid deposition and inflamma-
tion and the stimulation of neurogenesis demonstrated
in experimental studies might also contribute to the
clinical benefits of Cerebrolysin [9,12–14].
Although the neurotrophic-neuroprotective actions
of Cerebrolysin may account for its behavioural
effects in patients with AD, the discrepancy of doses
 2010 The Author(s)
 Cerebrolysin in moderate to moderately severe AlzheimerÕs disease
improving cognition (10–30 ml) and behaviour (60 ml)
suggests the involvement of different mechanisms. In
this regard, we recently found that 60-ml Cerebrolysin
reduced serum tumour necrosis factor alpha (TNF-a)
levels with respect to placebo in AD [37]. This finding
together with evidence of increased TNF-a in psychia-
tric disorders and its reduction after successful treat-
ment [38,39] suggests that changes in TNF-a might be
relevant for the effects of Cerebrolysin on behaviour.
Safety results indicate that dosages of up to 60-ml
Cerebrolysin are safe and well tolerated in patients with
moderate to moderately severe AD. No differences with
respect to placebo were found for the incidences of
adverse events, changes on laboratory parameters, vital
signs, physical and neurological examinations, or the
use of concomitant medications for any of the Cere-
brolysin doses evaluated.
This subgroup analysis indicates that Cerebrolysin is
effective at the 10-ml dose for the treatment of patients
with moderate to moderately severe AD. A stabilizing
effect of Cerebrolysin in these AD stages is suggested by
the persistence of its therapeutic benefits 3 months after
stopping treatment. These positive results of Cere-
brolysin have to be confirmed in larger RCTs.
References
1. Cummings JL. Treatment of AlzheimerÕs disease: the role
of symptomatic agents in an era of disease-modifying
therapies. Rev Neurol Dis 2007; 4: 57–62.
2. McShane R, Areosa Sastre A, Minakaran N. Memantine
for dementia. Cochrane Database Syst Rev 2006; 2:
CD003154.
3. Seow D, Gauthier S. Pharmacotherapy of Alzheimer
disease. Can J Psychiatr 2007; 52: 620–629.
4. Cattaneo A, Capsoni S, Paoletti F. Towards non invasive
nerve growth factor therapies for AlzheimerÕs disease.
J Alzheimers Dis 2008; 15: 255–283.
5. Wisniewski T, Konietzko U. Amyloid-beta immunisation
for AlzheimerÕs disease. Lancet Neurol 2008; 7: 805–811.
6. Herrmann N. Treatment of moderate to severe Alzhei-
merÕs disease: rationale and trial design. Can J Neurol Sci
2007; 34(Suppl.): 103S–108S.
7. Satou T, Itoh T, Fujimoto M, et al. Neurotrophic-like
effects of FPF-1070 on cultured neurons from chick
embryonic dorsal root ganglia. Jpn Pharmacol Ther 1994;
22: 205–212.
8. Akai F, Hiruma S, Sato T. Neurotrophic factor-like effect
of FPF1070 on septal cholinergic neurons after transec-
tions of fimbria-fornix in the rat brain. Histol Histopathol
1992; 7: 213–221.
9. Álvarez XA, Lombardi V, Fernández-Novoa L, et al.
Cerebrolysin reduces microglial activation in vivo and
in vitro: a potential mechanism of neuroprotection. J
Neural Transm 2000; 59: 281–292.
10. Masliah E, Armasolo F, Veinbergs I, et al. Cerebrolysin
ameliorates performance deficits, and neuronal damage in
apolipoprotein E-deficient mice. Pharmacol Biochem
Behav 1999; 62: 239–245.
 2010 The Author(s)
European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
67
11. Reinprecht I, Gschanes A, Windisch M, et al. Two pepti-
dergic drugs increase the synaptophysin immunoreactivity
in brains of 24-month-old rats. Histochem J 1999; 31: 395–
401.
12. Rockenstein E, Torrance M, Mante M, et al. Cere-
brolysin decreases amyloid-beta production by regulating
amyloid precursor protein maturation in a transgenic
model of AlzheimerÕs disease. J Neurosci Res 2006; 83:
1252–1261.
13. Chen H, Tung Y-C, Li B, et al. Trophic factors counteract
elevated FGF-2-induced inhibition of adult neurogenesis.
Neurobiol Aging 2007; 28: 1148–1162.
14. Rockenstein E, Mante M, Adame A, et al. Effects of
Cerebrolysin on neurogenesis in an APP transgenic
model of AlzheimerÕs disease. Acta Neuropathol 2007; 113:
265–275.
15. Alvarez XA, Cacabelos R, Laredo M, et al. A 24-week,
double-blind, placebo-controlled study of three dosages of
Cerebrolysin in patients with mild to moderate Alzhei-
merÕs disease. Eur J Neurol 2006; 13: 46–54.
16. Bae CY, Cho CY, Cho K, et al. A double-blind, placebo-
controlled, multicenter study of Cerebrolysin for Alzhei-
merÕs disease. J Am Geriatr Soc 2000; 48: 1566–1571.
17. Panisset M, Gauthier S, Moessler H, et al. Cerebrolysin in
AlzheimerÕs disease: a randomized, double-blind, placebo-
controlled trial with a neurotrophic agent. J Neural
Transm 2002; 109: 1089–1104.
18. Ruether E, Husmann R, Kinzler E, et al. A 28-week,
double-blind, placebo-controlled study with Cerebrolysin
in patients with mild to moderate AlzheimerÕs disease. Int
Clin Psychopharmacol 2001; 16: 253–263.
19. Xiao SF, Yan HQ, Yao PF, et al. Efficacy of FPF 1070
(Cerebrolysin) in patients with AlzheimerÕs disease. Clin
Drug Investig 2000; 19: 43–53.
20. Ruether E, Ritter R, Apecechea M, et al. Efficacy of the
peptidergic nootropic drug Cerebrolysin in patients with
senile dementia of the Alzheimer type (SDAT). Pharma-
copsychiatry 1994; 27: 32–40.
21. Mc Khann G, Drachman D, Folstein M. Clinical diag-
nosis of AlzheimerÕs disease: report of the NINCDS-
ADRDA Work Group under the auspices of the
Department of Health and Human Services Task Force
on AlzheimerÕs Disease. Neurology 1984; 34: 39–44.
22. Folstein MF, Folstein SE, McHugh PR. ‘‘Mini-Mental
State’’. A practical method for grading the cognitive state
of patients for the clinician. J Psychiatr Res 1975; 12: 189–
198.
23. Rosen WG, Terry RD, Fuld PA, et al. Pathological ver-
ification of ischemic score in differentiation of dementia.
Ann Neurol 1980; 7: 486–488.
24. Hamilton M. Development of a rating scale for primary
depressive illness. Br J Clin Psychol 1967; 6(4): 278–296.
25. Mohs RC, Knopman D, Petersen RC, et al. Development
of cognitive instruments for use in clinical trials of anti-
dementia drugs: additions to the AlzheimerÕs disease as-
sessment scale that broaden its scope. Alzheimer Dis Assoc
Disord 1997; 11(Suppl.): 13S–21S.
26. Knopman DS, Knapp MJ, Gracon SI, et al. The clinician
interview-based Impression (CIBI): a clinicianÕs global
change rating scale in AlzheimerÕs disease. Neurology
1994; 44: 2315–2321.
27. Rosen WG, Mohs RC, Davis KL. A new rating scale for
AlzheimerÕs disease. Am J Psychiatry 1984; 141: 1356–
1364.
68 X. A. Alvarez et al.
28. Cummings JL, Mega M, Gray K, et al. The neu-
ropsychiatric inventory: comprehensive assessment of py-
chopathology in dementia. Neurology 1994; 44: 2308–2314.
29. Gélinas I, Gauthier L, McIntyre M, et al. Development of
a functional measure for persons with AlzheimerÕs disease:
the disability assessment for dementia. Am J Occup Ther
1999; 53: 471–481.
30. Oswald WD, Roth E. Der Zahlenverbindungstest ZVT.
Goettingen, Germany: Verlag für Psychologie, 1978.
31. Doraiswamy PM, Krishnan KR, Anand R, et al. Long-
term effects of rivastigmine in moderately severe
AlzheimerÕs disease: does early initiation of therapy offer
sustained benefits? Prog Neuropsychopharmacol Biol
Psychiatry 2002; 26: 705–712.
32. Bullock R, Touchon J, Bergman H, et al. Rivastigmine
and Donepezil treatment in moderate to moderately-
severe AlzheimerÕs disease over a 2-year period. Curr Med
Res Opin 2005; 21: 1317–1327.
33. Kurz A, Farlow M, Quarg P, et al. Disease stage in Alz-
heimer disease and treatment effects of rivastigmine.
Alzheimer Dis Assoc Disord 2004; 18: 123–128.
34. Galasko D, Kershaw PR, Schneider L, et al. Galantamine
maintains the ability to perform activities of daily living in
European Journal of Neurology  2010 EFNS European Journal of Neurology 18, 59–68
patients with AlzheimerÕs disease. J Am Geriatr Soc 2004;
52: 1070–1078.
35. Gauthier S, Feldman H, Hecker J, et al. Functional,
cognitive and behavioural effects of Donepezil in patients
with moderate AlzheimerÕs disease. Curr Med Res Opin
2002; 18: 347–354.
36. Rogers SL, Farlow MR, Doody RS. A 24-week, dou-
ble-blind, placebo-controlled trial of donepezil in
patients with AlzheimerÕs disease. Neurology 1998; 50:
136–145.
37. Alvarez XA, Sampedro C, Cacabelos R, et al. Reduced
TNF-alpha and increased IGF-I levels in the serum of
Alzheimer patients treated with the neurotrophic agent
Cerebrolysin. Int J Neuropsychopharmacol 2009; 12: 867–
872.
38. Himmerich H, Fulda S, Linseisen J, et al. Depression,
comorbidities and the TNF-alpha system. Eur psychiatry
2008; 23: 421–429.
39. OÕBrien SM, Scully P, Fitzgerald P, et al. Plasma cytokine
profiles in depressed patients who fail to respond to
selective serotonin reuptake inhibitor therapy. J Psychiatr
Res 2007; 41: 326–331.
 2010 The Author(s)