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The Selective Muscarinic M1 Agonist AF102B Decreases Levels of Total A in Cerebrospinal Fluid of Patients with Alzheimers Disease

Roger M. Nitsch, MD,* Meihua Deng, PhD, Marsha Tennis, RN, David Schoenfeld, PhD, and John H. Growdon, MD
-Amyloid (A ) deposits in diffuse and compact senile plaques in the brain are one of the defining histopathological features of Alzheimers disease (AD). Preventing A deposition is a goal of drug therapy for AD, because excessive amounts of A may be toxic to neurons. In preclinical studies, activation of the muscarinic M1 receptor subtype inhibited A secretion from cultured cells. To determine whether a similar sequence occurs in human beings, we administered the selective M1 agonist AF102B to 19 AD patients and measured total A (A total) levels in cerebrospinal fluid (CSF) before and during treatment. A total levels in CSF decreased in 14 patients by 22%, increased in 3 patients, and were unchanged in 2 patients; the overall decrease in the group as a whole was statistically significant. To test the specificity of the M1 effect, we also measured the relative changes in A total levels in CSF during treatments in separate sets of AD patients with the acetylcholinesterase inhibitor physostigmine or the anti-inflammatory drug hydroxychloroquine. CSF A total levels did not change significantly in the 9 AD patients in the physostigmine protocol or in the 10 AD patients in the hydroxychloroquine study. These data provide evidence that the activation of M1 receptors reduces A levels in the CSF of AD patients. If this effect also occurs in brain, M1 agonists may have long-term therapeutic benefits by lowering amyloid in AD. Nitsch RM, Deng M, Tennis M, Schoenfeld D, Growdon JH. The selective muscarinic M1 agonist AF102B decreases levels of total A in cerebrospinal fluid of patients with Alzheimers disease. Ann Neurol 2000;48:913918

-Amyloid deposits in the brain are one of the defining histopathological features of Alzheimers disease (AD). According to the amyloid cascade hypothesis, early -amyloid deposits trigger a series of neurotoxic events that eventually lead to synapse loss and neuronal degeneration. Preventing -amyloid deposition is thus a leading target for drug development in AD. Brain -amyloid is composed of a 40-42amino acid peptide called A , which is cleaved from a large amyloid precursor protein (APP) by the action of - and -secretases. Activation of another enzyme, -secretase, splits APP within its A domain and prevents the formation of A . In a series of cell culture and brain slice experiments, we showed that APP processing via the -secretase pathway can be activated by cell surface receptors that are linked to a phospholipase C-diacylglycerol second messenger system.1 4 Cell surface receptors that mediate this re-

sponse include muscarinic M1 and M3 receptors, serotonergic 5-HT 2b and 2c receptors, metabotropic glutamate mGlu R1 receptors, and certain neuropeptide receptors. Hung and co-workers5 subsequently found that cholinergic stimulation of cells transfected with the M1 subtype simultaneously increased the soluble N-terminal APP ectodomain generated by -secretase cleavage while inhibiting A production. If such a sequence were to occur in human beings, administration of an M1 agonist would be expected to decrease levels of A in the central nervous system and possibly to slow the course of AD dementia. To test this hypothesis, we administered the selective M1 and M3 agonist AF102B to 19 patients with a clinical diagnosis of AD and measured cerebrospinal fluid (CSF) levels of soluble A before and during drug administration.

From the *Division of Psychiatry Research, University of Zurich, Zurich, Switzerland; and Department of Neurology and Department of Medicine, Biostatistics Center, Massachusetts General Hospital, Boston, MA. Received Apr 10, 2000, and in revised form Jul 19. Accepted for publication Jul 21, 2000.

Address correspondence to Dr Growdon, WACC 830, Massachusetts General Hospital, Fruit Street, Boston, MA 02114.

Copyright 2000 by the American Neurological Association

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Subjects and Methods Subjects The 19 participants in the AF102B study all had a clinical diagnosis of AD.6 Of the 19 patients, 3 died from causes unrelated to the drug after the study was completed; AD was confirmed neuropathologically in all 3. There were 9 men and 10 women in this study (Table). Their mean age was 72.2 10.1 (mean SD) years, and the mean duration of their illness was 4.9 2.9 years. The severity of dementia was estimated by the Information, Memory, and Concentration (IMC) subscale of the Blessed Dementia Scale7 score, in which 0 to 2 is normal and rising scores up to a maximum of 37 indicate increasing dementia severity. The mean IMC score was 19.4 9.8. We determined each patients apolipoprotein E (ApoE) genotype by a polymerase chain reaction8 method: 5 had two E4 alleles, 10 had one E4 allele, 3 had no E4 alleles, and genotype analysis was not performed in 1. Medication AF102B is a selective muscarinic M1 and M3 agonist that is a conformationally rigid analogue of acetylcholine.9 In cell culture, AF102B activates -secretase APP processing as indexed by an increase in APP secretion (APPs).10 AF102B is active in the brain as judged by improved spatial learning in mice11 and reversal of impaired maze performance in aged rats.12 Peak effects occur within 60 minutes after oral administration; brain concentrations peak 30 minutes after administration. In human beings, AF102B plasma concentrations peak at 1 to 2 hours after oral administration; the plasma half-life ranges between 2 and 5 hours. Protocol Subjects (with spousal consent) agreed to participate in this study according to the provisions of the protocol approved by the Massachusetts General Hospital (MGH) Institutional Review Board. Patients were admitted to the MGH General Clinical Research Center for lumbar punctures on two occasions: at baseline before treatment and during the fourth week of maximal
Table. Clinical Characteristics of Patients in the Three Drug Trials Sex M AF102B (n 19) Hydroxychloroquine (n 10) Physostigmine (n 9)
a

treatment. AF102B was supplied by Snow Brand Milk Products Company (Tokyo, Japan) and was administered in escalating doses with 20 mg three times daily during week 1, 40 mg three times daily during week 2, 60 mg three times daily during week 3, and 80 mg three times daily during week 4. Spinal fluid was collected according to conventional lumbar puncture techniques. CSF was immediately divided into 500- l aliquots and frozen on dry ice at the bedside. Samples were stored at 80C until biochemical assay. We used a sensitive and specific sandwich enzyme-linked immunosorbent assay (ELISA) method to measure total A (A total A 40 A 42) in 25 l of CSF. The antibodies were 22C4, a monoclonal antibody raised against a KLH-conjugated peptide corresponding to the C-termini of A 40 and A 42 for capture and biotinylated 6E10 (purchased from Senetec, St Louis, MO) directed against their N-termini as the detection antibody. We used 25 l of CSF so as to fall into the linear range (0.6 20 ng) of the assay, which was reproducible with intra-assay variances of less than 10%. In 11 cases in which we had sufficient CSF, we also analyzed A total by Western blot analysis with 6E10 and densitometry. To determine the specificity of AF102B on CSF A levels, we administered two other drugs, hydroxychloroquine or physostigmine, to separate sets of AD patients. There were 10 AD patients (7 men and 3 women) in the hydroxychloroquine study. They had a mean age of 68.3 6.9 years, a mean duration of illness of 3.8 1.9 years, and a mean IMC score of 19.5 13.1 (see Table). There were 9 AD patients in the physostigmine protocol (3 men and 6 women). They had a mean age of 67.7 9.3, a mean duration of illness of 3.8 1.5 years, and a mean IMC score of 13.2 8.9. Hydroxychloroquine is an anti-malarial and anti-rheumatic drug that is also effective in lupus erythematosus and rheumatoid arthritis. The mechanism for its action in collagen diseases is not clearly known. We tested hydroxychloroquine because of its

F 10 3 6

Age, yr (mean SD) 72.2 68.3 67.7 10.1 6.9 9.3

Duration of illness (yr) (mean SD) 4.9 3.8 3.8 2.9 1.9 1.5

IMC Score (mean SD) 19.4 19.5 13.2 9.8 13.1 8.9

Baseline CSF A total (mean SD) 22.8 23.5 21.2 7.5 10.1 7.9

Treatment CSF A total (mean SD) 19.9 24.0 21.0 7.9a 8.1 6.1

9 7 3

0.004. male; F female; IMC Information, Memory, and Concentration subtest of the Blessed Dementia Scale7; CSF cerebrospinal fluid.

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anti-inflammatory property and also because it inhibits lysosomal protease function and thereby may interfere with APP processing.13 Subjects took 200 mg of hydroxychloroquine twice daily, which was supplied by Sanofi Pharmaceuticals (New York, NY). Physostigmine is an acetylcholine esterase inhibitor. The net effect of its administration is to increase cholinergic neurotransmission by inhibiting the enzymatic hydrolysis of endogenously released acetylcholine. Physostigmine was provided by Forest Laboratories (New York, NY) as a sustained-release tablet. Of the 9 patients, 2 took a total of 9 mg/day, 1 took 12 mg/day, and 6 took 15 mg/day. As in the AF102B protocol, each patient underwent a baseline lumbar puncture and then a repeat lumbar puncture during the fourth week of treatment. In all protocols, CSF samples were collected in 500- l aliquots, frozen immediately at the bedside, stored at 80C, and assayed according to identical procedures. The primary outcome measure of this study was a change in CSF A levels during treatment. In these experiments, changes in CSF A levels served as surrogate markers to monitor drug effects, because A levels in CSF remain stable over time14 in the untreated state. CSF A total levels were not used as biomarkers to diagnose AD, because mean values overlap with those of normal control subjects.15 A two-tailed t test was used to compare mean changes before and after drug administration. Analyses of covariates were employed to examine whether the changes correlated with age, gender, dementia severity, and ApoE genotype. Results Individual CSF levels of A at baseline ranged from 9.13 to 31.27 ng/ml (mean SD, 22.8 7.5 ng/ml). During treatment, these levels decreased by a median of 22% in 14 patients, increased in 3, and were unchanged in 2 (mean SD: 19.9 7.9 ng/ml) (Fig 1). The mean decrease of 2.9 0.9 ng/ml during treatment was statistically significant ( p 0.004). The change in A total was not related to the dose of medication; it did not correlate with age, sex, dementia severity, or ApoE genotype. We verified the identity of A total in CSF by Western immunoblot densitometry. When quantitated by densitometry, there was good correspondence (r 0.937) between the relative change in A total detected by the ELISA assay and by Western immunoblotting (Fig 2). In contrast to A total, levels of A 4216 and soluble N-terminal APP ectodomain derivatives measured by ELISA and Western immunoblots did not change in CSF in a consistent or statistically significant way during drug treatment (data not shown). The most common side effects of AF102B were excessive sweating, gastrointestinal complaints, and headache. Many of these symptoms may result from activating M3 receptors. In most cases, symptoms subsided

Fig 1. AF102B significantly (p 0.004) decreased cerebrospinal fluid levels of ABtotal in Alzheimers disease patients. Each bar represents the percentage of change from baseline during treatment in an individual patient.

several hours after medication ingestion. One patient withdrew from the study because of persistent fever, chills, and abdominal cramps. A second patient was hospitalized for persistent vomiting that began 27 days after completing the AF102B study. Gastric endoscopy revealed esophagitis that resolved with conservative medical treatment. CSF A total levels did not change significantly in AD patients who took hydroxychloroquine or physostigmine. Mean levels of A total in the hydroxychloroquine study at baseline were 23.5 10.1 and 24.0 8.1 ng/ml during the final week of treatment. Among the 10 hydroxychloroquine patients, CSF
Fig 2. The correlation between enzyme-linked immunosorbent assay and Western immunoblot methods for measuring A total levels in cerebrospinal fluid is excellent (r 0.937). Each treatment point represents the relative change (baseline A A ) in a single patient. Points below 1.0 are those in which levels are decreased, and points above 1.0 are those in which levels are increased.

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A total levels increased in 5, decreased in 2, and were unchanged in 3. Mean CSF A total levels in the physostigmine study were 21.2 7.9 ng/ml at baseline and 21.0 6.1 ng/ml during treatment. Among the 9 physostigmine patients, CSF A total levels increased in 4, decreased in 4, and were unchanged in 1. Discussion The results of this study indicate that the selective M1 agonist AF102B decreased levels of A total in the CSF of most AD patients. This result is consistent with our underlying scientific rationale for administering M1 and M3 agonists, which was originally based on in vitro experiments with transfected cells.1,5 This result is also consistent with an in vivo study on cholinergic effects of APP processing in rats. Lin and co-workers17 administered the muscarinic agonist RS86 to normal rats, aged rats, and rats with basal forebrain cholinergic deficits and measured levels of cell-associated APP in brain tissue and the APPs in CSF. They found that treatment decreased APP levels in neocortex and hippocampus and increased levels of APPs in CSF in aged as well as cholinergically denervated rats. That study was the first in vivo demonstration that increased cholinergic neurotransmission can enhance nonamyloidogenic APP processing. Our finding with AF102B extends the preclinical results of cholinergic influences on APP processing to human beings and establishes that selective M1 and M3 agonists can decrease A levels in the CSF of AD patients. In contrast to the RS86 finding in animals,17 APPs levels did not increase during treatment with AF102B. An obvious explanation for decreased A with no associated increase in APPs- would be inhibition of -secretase. To our knowledge, the possibility that AF102B inhibits -secretase activity has never been examined. Clinical studies cannot establish biological mechanisms unequivocally, but our finding should prompt further investigations into the biochemical effects of AF102B on -secretase. For example, among the many signaling events coupled to muscarinic receptor stimulation is the phosphorylation of presenilin 1 (PS-1).18 PS-1 is either a -secretase or is closely linked to its activity.19 Phosphorylating PS-1 may well be involved in regulating its endoproteolysis, facilitating its assembly into the PS-1 enzymatic complex and leading ultimately to its biological activity. In our study, the main outcome measure was A total. The assay for A total captures and measures both A 40 and A 42 moieties. Most A circulating in the CSF is A 40, whereas A 42 accounts for only about 10%. The fact that A 42 levels did not change during treatment may reflect its relatively small contribution to the total A measurement. Alternatively, it is possible that AF102B exerts a selective drug effect on - and

-secretase processing of APP, with predominant inhibition of A 40 production. To determine whether the decrease in A total induced by AF102B is specific to M1 agonists or occurs with other pharmacological treatments, we tested two other drugs in separate sets of AD patients: the acetylcholine esterase inhibitor physostigmine and the antiinflammatory drug hydroxychloroquine. Physostigmine given in doses that improved cognition in clinical studies20,21 failed to change CSF A total levels in our study. This finding is consistent with our prior preclinical studies, in which we found that physostigmine did not alter APP processing.22 Although physostigmine increases cholinergic neurotransmission, the effect is nonspecific and extends to all muscarinic receptors. Whereas stimulation of M1 and M3 receptors increases -secretase APP processing, activation of M2 receptors does not1; simultaneous stimulation of M2 receptors blocks the M1 stimulation effect.22 Anti-inflammatory drugs are being evaluated as a treatment for AD following the observation of microglia activation surrounding amyloid plaques. Hydroxychloroquine administration did not significantly alter A total CSF levels in AD patients. The fact that neither of these drugs influenced CSF levels of A total emphasizes the specificity of the AF102B effect on APP processing. The goal of our study was to determine whether an M1 muscarinic agonist would alter APP processing in human beings as hypothesized from preclinical studies. The scientific rationale behind this study is therefore much different from prior clinical trials with M1 agonists that were based solely on a neurotransmitter replacement strategy.23 The initial rationale for developing muscarinic agonists was based on increasing acetylcholine neurotransmission according to the tenets of the cholinergic hypothesis of memory dysfunction.24 Because postsynaptic receptor sites, especially M1 receptors, are largely preserved in the face of significant decrements in presynaptic indices of cholinergic neurons,25 it was hoped that M1 agonists would correct the cholinergic neurotransmitter deficit in AD and thereby restore memory capabilities. To date, predictions of short-term symptomatic benefit have not been realized. Of several M1 agonists that have entered clinical development, xanomeline was the most carefully studied. In a large clinical trial, its administration nearly abolished psychotic signs in AD patients such as delusions and hallucinations but did not improve cognition.26 In our study, we sought changes in APP processing in CSF; we did not expect, or measure, shortterm changes in behavior or cognition. The results of our study indicate that compounds stimulating M1 and M3 receptors decrease A secretion in AD patients and suggest that this class of drugs should therefore be re-evaluated as a treatment for AD. In contrast to simple neurotransmitter replacement, our study raises the

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possibility that muscarinic agonists that stimulate M1 or M3 receptors may prevent or slow neurodegeneration by lowering amyloid in AD patients. The development of drugs that either block A production, prevent its aggregation and deposition in brain tissue, or enhance its clearance is a major theme in AD therapeutics. In a transgenic mouse model, Schenk and co-workers27 discovered that immunization with the A 42amino acid peptide sequence prevented amyloid deposition in the brain. Moreover, drugs that inhibit - or -secretase processing of APP may also prevent A deposition. The development of this line of therapeutics was greatly facilitated by the identification of -secretase28 and by the possibility that PS-1 is a -secretase.19 In addition to these approaches, neurotransmitter agonists that activate -secretase processing may be useful to reduce A formation. As these preclinical experiments lead to drugs for clinical trials, it is important to verify that these treatments are acting as proposed in human beings. The usual outcomes for drug studies in AD rely on short-term changes in cognitive test performance29,30 or on long-term behavioral outcomes.31 In future trials, it would be advantageous to have an accepted biomarker of AD pathology used as a surrogate outcome for drug effect; direct measures of amyloid in the brain may be performed in mice but are impossible in human beings. Amyloid deposits in the brain do not correlate with the duration or severity of dementia32 and A levels in CSF apparently do not change across clinical estimates of dementia severity or over time.14 Our study with AF102B indicates that A measurements in CSF do change with treatment and can therefore be used as a reasonable correlate of drug action. Thus, drugs that are proposed to decrease A production such as - or -secretase inhibitors would be expected to decrease A levels in CSF, whereas drugs that increase A clearance from the brain might actually increase A levels in CSF or plasma. Our experience in this study argues in favor of measuring a full panel of APP derivatives, including p3, so as to capture unexpected complexities of drug effects on APP processing in human patients. Measuring a change in any APP derivative in CSF can provide supportive evidence of a drugs mode of action; druginduced changes in CSF may not accurately reflect amyloid formation in the brain, however. Whether amyloid-reducing therapies prevent or even slow the progressive course of AD dementia continues to rely on clinical and behavioral measures.
This study was supported by grants from the National Institutes of Health (P50 AG 05134) and the Snow Brand Milk Products Company. The MGH Clinical Research Center is supported by National Institutes of Health grant 5-MO1-01066-23. The authors are not employed by Snow Brand Milk Products Company, do not serve as consultants, and do not have any financial interest in the company.

We thank Dr Dominic Walsh for the A 42 measurements and Dr Manfred Brockhaus for the APPs ELISA measurements.

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