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PubMed2004

Treatment of Alzheimer's disease: current and future therapeutic approaches.

The pathophysiology of Alzheimer's disease (AD) includes the deposition of amyloid beta protein (Abeta) and the ensuing initiation of a variety of secondary processes, including tau hyperphosphorylation, excitotoxicity, oxidation, and inflammation. Nerve cell loss in structures responsible for manufacturing neurotransmitters results in a variety of neurochemical deficits. Current therapeutic approaches to the treatment of AD include cholinesterase inhibitors for mild to moderate disease, memantine for moderate to severe disease, and vitamin E or selegiline. Reduction of Abeta generation or aggregation, enhancement of Abeta removal, interruption of tau hyperphosphorylation, and the use of more efficacious antioxidant or anti-inflammatory agents represent promising therapeutic strategies currently being investigated. Improved methodologies for clinical trial design and analysis and the development of biological markers may hasten the identification of effective treatments for AD.

Alzheimer Disease↗
PubMedDate not supplied

[New therapeutic options in Alzheimer's disease].

INTRODUCTION: At present, cholinesterase inhibitors constitute the basis for therapy of Alzheimer's disease (AD); these drugs were rationally introduced given the loss of central cholinergic neurotransmission, even though there are many other systems affected in AD, including glutamatergic pathway. DEVELOPMENT: In addition to the loss of central cholinergic neurotransmission, biochemical evidence suggests glutamatergic dysfunction in AD and thus, therapeutic strategies directed at the glutamatergic system may be useful. These drugs include milacemide, cicloserine and ampakines (positive modulation) and memantine (negative modulation). Lithium seems to be a promising agent in AD, although the mechanism of action is poorly understood. Finally anti-inflammatory agents may be another therapeutic approach to AD. CONCLUSION: In addition to drugs acting on the cholinergic system, a large number of drugs with different mechanism could be used for the treatment and prevention of AD.

Acetamides↗
PubMed2006

Navigating patients and caregivers through the course of Alzheimer's disease.

Alzheimer's disease (AD) prevalence rates in the United States are expected to triple over the next 50 years, a consequence of the overall aging of the U.S. population. Because of the profound and far-reaching impact of AD, this projected increase in prevalence is expected to pose a tremendous challenge. Alzheimer's disease results in the cognitive and functional deterioration of the affected patient, and behavioral disturbances frequently accompany the disease. Furthermore, because of its progressive and debilitating nature, AD takes a dramatic emotional, physical, and financial toll on the patient's primary caregiver. Nonetheless, despite the burden experienced by both patients and caregivers, strategies for minimizing the negative consequences of AD are well characterized. Central to the successful management of AD is the prompt and accurate diagnosis of the disease, with current guidelines calling for a 2-tiered approach in which patients first undergo screening using a brief cognitive assessment tool, followed by a comprehensive battery of physical, psychological, and neurologic tests if signs of possible cognitive impairment are evident upon screening. Once a conclusive diagnosis of AD has been made, the development of a disease management approach targeting the needs of the patient and his or her caregiver becomes a primary concern. Pharmacologic interventions may play an important role in such approaches, as agents such as cholinesterase inhibitors and the N-methyl-D-aspartate receptor antagonist memantine have been associated with favorable outcomes for patients and caregivers alike. However, in addition to the therapeutic benefits of these agents, associated side effects and potential drug-drug interactions must also factor into decisions regarding the pharmacologic treatment of AD.

Aged↗
PubMed2006

What's new in clinical pharmacology and therapeutics.

The US Food and Drug Administration (FDA) has approved several new drugs in the last few years. We have summarized a few of these that should be of interest to a primary care physician. These belong to either a new class of drugs or have a better drug profile in terms of ease of administration, prolonged duration of action, or fewer side effects. Daptomycin is a cyclic lipopeptide, active against methycillin resistant Staphylococcus aureus (MRSA). Telithromycin is a ketolide that can be used in place of macrolide antibiotics. Rifaximin is a semi-synthetic derivative of rifampin approved by the FDA for treatment of traveller's diarrhea. Pramlintide is an injectable synthetic amylin useful in treating type 1 and 2 diabetes. Tiotropium is an anti-cholinergic bronchodilator that can be taken once a day for treatment of chronic obstructive pulmonary disease. Lanthanum Carbonate is useful in treatment of hyperphosphatemia in patients with end stage renal disease. Flumist is an intranasal influenza vaccine. Eszopiclone is a new hypnotic that has fewer side effects. Memantine is in a new class of drugs useful in the treatment of Alzheimer's disease. Ibandronate is a new bisphosphonate approved for once a month use for osteoporosis in postmenopausal women. Acamprosate is approved for treatment of alcohol dependence.

Acamprosate↗
PubMed2006

Alzheimer's disease: beware of interactions with cholinesterase inhibitors.

(1) Cholinesterase inhibitors such as donepezil, galantamine and rivastigmine, are not very effective in slowing the cognitive decline associated with Alzheimer's disease. Memantine, which is no more effective, has dopaminergic and atropinic effects but is not a cholinesterase inhibitor. (2) Cholinesterase inhibitors have mainly cholinergic adverse effects, causing gastrointestinal, neurological, cardiovascular and urinary disorders (incontinence). (3) Increased mortality, mainly due to cardiovascular events, was observed in placebo-controlled trials of galantamine. In one trial there were more deaths in patients on donepezil than on placebo. (4) Atropinic drugs tend to aggravate cognitive disorders that are treated with cholinesterase inhibitors. (5) Cholinesterase inhibitor + neuroleptic combinations are associated with an increased risk of extrapyramidal adverse effects. An increase in mortality was reported during trials of neuroleptics involving patients with dementia, and also during trials of cholinesterase inhibitors. (6) Combining cholinesterase inhibitors with drugs that reduce the heart rate, depress cardiac conduction, or induce torsades de pointes increases the risk of arrhythmias and cardiac conduction disorders. (7) Donepezil and galantamine are metabolised by cytochrome P450 isoenzymes 3A4 and 2D6, creating a strong potential for pharmacokinetic interactions with inhibitors and inducers of these isoenzymes. Rivastigmine is mainly metabolised by cholinesterases, and binds poorly to cytochrome P450 isoenzymes. (8) Cholinesterase inhibitors inhibit the metabolism of suxamethonium and thereby augment and prolong the neuromuscular blockade induced by this curare. (9) In practice, caregivers should be aware of the potential adverse effects of cholinesterase inhibitors, which often resemble symptoms of Alzheimer's disease and may be due to drug-drug interactions or to antagonist effects with other drugs, such as those with atropinic effects. Additionally, the many adverse effects associated with the use of cholinesterase inhibitors highlights the need for regular re-evaluation of the use of these medicines and of the balance of benefit versus risk in individual patients.

Alzheimer Disease↗
PubMed2006

The synergistic effect of selective sigma receptor agonists and uncompetitive NMDA receptor antagonists in the forced swim test in rats.

Data acquired to date show that some sigma receptor ligands reveal "antidepressant-like" activity in the forced swim test in mice and rats. Moreover, our preliminary results suggested that joint administration of sigma receptor ligands and amantadine (AMA, a glutamatergic/NMDA receptor antagonist) caused a positive interaction in the Porsolt test in rats, as had already been observed in the case of co-treatment with clinically active antidepressants and AMA. The aim of the present study was to examine the effect of combined administration of sigma1 or sigma2 receptor agonists, SA4503 or siramesine, respectively, and AMA or memantine (MEM) (uncompetitive NMDA receptor antagonist). SA4503 or siramesine given jointly with MEM (as well as with AMA) decreased the immobility time in rats. The effect of SA4503 and AMA co-administration was antagonized by progesterone, a sigma1 receptor antagonistic neurosteroid. Combined treatment with siramesine and AMA was modified by neither progesterone nor BD1047 (a novel sigma antagonist with preferential affinity for sigma1 sites); but it was counteracted by sulpiride and prazosin (a dopamine D2- and an alpha1-adrenergic receptor antagonist, respectively). The "antidepressant-like" effect induced by siramesine and MEM was not antagonized by progesterone, but was attenuated by BD1047, sulpiride and prazosin. The obtained results give support to the hypothesis that sigma (particularly sigma1) receptors may be one of the possible mechanisms by which drugs induce antidepressant-like activity in the forced swim test, and that this effect may be enhanced by NMDA receptor antagonists. Combined treatment with sigma ligands and AMA or MEM (applied in the clinic) may be an alternative to the treatment of antidepressant-resistant depressive patients in the future.

Adrenergic alpha-Antagonists↗
PubMedDate not supplied

Realistic expectations for treatment success in Alzheimer's disease.

Alzheimer's disease (AD) is a progressive degenerative disease that warrants active management to delay or slow progression of its symptoms. The symptoms of AD encompass behavior and daily function as well as cognition, so clinicians should take a global view in the assessment of treatment success. Because there is currently no cure for AD, one cannot expect an initial cognitive improvement observed in the first few months of therapy to be sustained indefinitely. However, one should expect that the patient who is treated early and persistently with medication for AD will show less evidence of behavioral, functional, and cognitive deterioration over a period of time than one would expect in the absence of pharmacotherapy. Thus, treatment success includes not only short-term improvement of symptoms but also less decline over the long term. Determination of treatment success therefore also requires awareness of the typical progression of untreated AD. In this article we review the natural history of AD and evidence for the effectiveness of the treatments indicated for AD: donepezil, galantamine, rivastigmine, and memantine.

Aged↗
PubMedDate not supplied

Effect of BD 1047, a sigma1 receptor antagonist, in the animal models predictive of antipsychotic activity.

The sigma receptors were first classified as a subtype of opioid receptors but later they were found to be a distinct pharmacological entity. Many preclinical and clinical data have indicated that sigma receptor ligands have to be involved in neuropsychiatric disorders, including schizophrenia. Numerous data have suggested that potential antipsychotic activity of sigma ligands results from their "antagonistic" activity. However, the subcellular mechanisms by which sigma ligands exert their effects have not been elucidated in detail, therefore, the terms "agonist" or "antagonist" and their functional implications are not entirely unequivocal. The aim of the present study was to find out if BD 1047, described recently as a selective functional antagonist of sigma receptors, shows antipsychotic activity in animal models predictive of efficacy in schizophrenia. In contrast to rimcazole and panamesine, two selective sigma ligands whose antipsychotic activity was confirmed clinically, BD 1047 did not decrease amphetamine-induced hyperactivity in mice in a statistically significant manner. Likewise, it did not modify the hyperactivity induced by NMDA receptor antagonists, phencyclidine, memantine or dizocilpine. On the other hand, BD 1047 attenuated apomorphine-induced climbing in mice and phencyclidine-induced head twitches in rats, like rimcazole and panamesine did. Summing up, BD 1047 shows a moderate activity in models used in this study suggesting that its usefulness as an antipsychtic drug is doubtful. However, more detailed studies are required for definitive confirmation of this conclusion.

Animals↗
PubMed1977

Effects of 1,3-dimethyl-5-aminoadamantane hydrochloride (DMAA) on the stretch-induced reflex tension of flexor muscles and the excitability of the gamma-loop in decerebrate and spinal cats.

The effects of 10 mg/kg i.v. 1,3-dimethyl-5-aminoadamantane hydrochloride (memantine, DMAA) on the stretch-induced reflex tension of flexor muscles extensor digitorum longus and tibialis anterior (EDL/TA) and on the excitability of the neurons relaying transmission in the gamma-loop have been investigated in decerebrate and spinal cats. DMAA essentially reduced the relfex excitability of flexors EDL/TA induced by fusimotor activity in the decerebrate preparation. The drug did not stimulate the reflex activity in acute spinal cats. In the concentration used, DMAA suppressed largely the transmission of the fusimotor reflex in the decerebrate as well as in the spinal preparation, although in spinal cats DMAA increased the average firing rate of muscle spindle primaries originating from EDL/TA muscles. The possible mechanism of action of the compound on dopaminergic and serotonergic systems as well as its basic effects on neuronal membranes is discussed.

Amantadine↗
PubMed1977

[The action of 1-aminoadamantane. Comparative studies with isolated nerve endings and thrombocytes on the release of serotonin and dopamine].

Nerve endings isolated from rat brain accumulate exogenous serotonin and dopamine. Both biogenic amines are released from nerve endings as well by means of electrical stimulation with rectangular pulses of alternating polarity as by incubation with 5 X 10(-4) to 5 X 10(-5) M solutions of the adamantane derivatives 1-aminoadamantane hydrochloride (D 1) and 1-amino-3,5-dimethyladamantane hydrochloride (memantine, D 145). The electrically stimulated liberation is small but is significantly increased after simultaneous incubation of the nerve endings with subthreshold concentrations of 1-aminoadamantanes (5X10(-6) to 5X10(-5) M). The reuptake of released serotonin is noncompetitively inhibited by 1-aminoadamantanes. Also in blood platelets frequently used as model cells of the nerve endings the serotonin uptake is inhibited by small concentrations of D 145, 10(-5) to 2X10(-4) M. High concentrations of D 145- greater than 2X10(-3) M, induce the "release-reaction", the simultaneous liberation of serotonin, ATP, and ADP. In the concentration range of 2X10(-4) to 2X10(-3) M D 145 only serotonin is set free.

Amantadine↗
PubMed1993

HIV-1 gp120 and NMDA induce protein kinase C translocation differentially in rat primary neuronal cultures.

Exposure of rat cortical neurons to the human immunodeficiency virus type 1 (HIV-1) coat protein gp120 in vitro causes a rise in the intracellular Ca2+ level and a subsequent translocation of protein kinase C (PKC) from the cytosol to the membrane. Such a translocation persists for at least 2 h, but only in cultures with media not depleted of endogenous glutamate. Enzymatic degradation of glutamate in the medium by the enzyme glutamate-pyruvate transaminase (GPT) abolishes the long-lasting effect of gp120 on the association state of PKC; under this incubation condition the translocation period is < 1 h. Memantine and the ganglioside GM1 prevent N-methyl D-aspartate receptor-mediated long-term translocation of PKC and gp120-mediated neurotoxicity (in the absence of GPT); they have no effect on short-term translocation of PKC. We suggest that gp120-caused neuronal death involves an indirect sensitization step of the NMDA receptors, which ultimately induces neuronal death.

Animals↗
PubMed1996

[New therapeutic possibilities with low-affinity NMDA receptor antagonists].

Glutamate receptor antagonists with selective action at the N-methyl-D-aspartate (NMDA) receptor are promising agents for the neuroprotective and symptomatic pharmacotherapy of various neuropsychiatric disorders. Although NMDA receptor antagonists of the phencyclidine (PCP) type are precluded from clinical use because of their psychotomimetic properties, amantadine and memantine have been administered to human patients with idiopathic Parkinson's disease and spasticity for many years without serious adverse effects. The mechanisms underlying these differences in psychotogenicity of different NMDA receptor antagonist are currently being discussed. Different affinity to the PCP binding site of the NMDA receptor, region-specific pharmacology, as well as different binding profiles to neurotransmitter receptors other than the NMDA type glutamate receptor, most likely play a role in determining whether an NMDA receptor antagonist drug will be tolerated clinically or not.

Aged↗
PubMed2004

Mixed dementia: emerging concepts and therapeutic implications.

CONTEXT: The prevalence of mixed dementia, defined as the coexistence of Alzheimer disease (AD) and vascular dementia (VaD), is likely to increase as the population ages. OBJECTIVES: To provide an overview of the diagnosis, pathophysiology, and interaction of AD and VaD in mixed dementia, and to provide a systematic literature review of the current evidence for the pharmacologic therapy of mixed dementia. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: The Cochrane Database of Systematic Reviews was searched using the keyword dementia. MEDLINE was searched for English-language articles published within the last 10 years using the keywords mixed dementia, the combination of keywords Alzheimer disease, cerebrovascular disorders, and drug therapy, and the combination of keywords vascular dementia and drug therapy. EVIDENCE SYNTHESIS: Dementia is more likely to be present when vascular and AD lesions coexist, a situation that is especially common with increasing age. The measured benefits in clinical trials for the treatment of mixed dementia are best described as statistically significant differences in cognitive test scores and clinician and caregiver impressions of change. In these studies, the control groups' scores typically decline while the treatment groups improve slightly or decline to a lesser degree over the study period. Nevertheless, even the patients who experience treatment benefits eventually decline. Cholinesterase inhibitor (ChI) therapy for mixed dementia shows modest clinical benefits that are similar to those found for ChI treatment of AD. The N-methyl-D-aspartate (NMDA) antagonist memantine also shows modest clinical benefits for the treatment of moderate to severe AD and mild to moderate VaD, but it has not been studied specifically in mixed dementia. The treatment of cardiovascular risk factors, especially hypertension, may be a more effective way to protect brain function as primary, secondary, and tertiary prevention for mixed dementia. CONCLUSIONS: Currently available medications provide only modest clinical benefits once a patient has developed mixed dementia. Cardiovascular risk factor control, especially for hypertension and hyperlipidemia, as well as other interventions to prevent recurrent stroke, likely represent important strategies for preventing or slowing the progression of mixed dementia. Additional research is needed to define better what individuals and families hope to achieve from dementia treatment and to determine the most appropriate use of medication to achieve these goals.

Alzheimer Disease↗
PubMed2005

Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence.

CONTEXT: Neuropsychiatric symptoms of dementia are common and associated with poor outcomes for patients and caregivers. Although nonpharmacological interventions should be the first line of treatment, a wide variety of pharmacological agents are used in the management of neuropsychiatric symptoms; therefore, concise, current, evidence-based recommendations are needed. OBJECTIVE: To evaluate the efficacy of pharmacological agents used in the treatment of neuropsychiatric symptoms of dementia. EVIDENCE ACQUISITION: A systematic review of English-language articles published from 1966 to July 2004 using MEDLINE, the Cochrane Database of Systematic Reviews, and a manual search of bibliographies was conducted. Inclusion criteria were double-blind, placebo-controlled, randomized controlled trials (RCTs) or meta-analyses of any drug therapy for patients with dementia that included neuropsychiatric outcomes. Trials reporting only depression outcomes were excluded. Data on the inclusion criteria, patients, methods, results, and quality of each study were independently abstracted. Twenty-nine articles met inclusion criteria. EVIDENCE SYNTHESIS: For typical antipsychotics, 2 meta-analyses and 2 RCTs were included. Generally, no difference among specific agents was found, efficacy was small at best, and adverse effects were common. Six RCTs with atypical antipsychotics were included; results showed modest, statistically significant efficacy of olanzapine and risperidone, with minimal adverse effects at lower doses. Atypical antipsychotics are associated with an increased risk of stroke. There have been no RCTs designed to directly compare the efficacy of typical and atypical antipsychotics. Five trials of antidepressants were included; results showed no efficacy for treating neuropsychiatric symptoms other than depression, with the exception of 1 study of citalopram. For mood stabilizers, 3 RCTs investigating valproate showed no efficacy. Two small RCTs of carbamazepine had conflicting results. Two meta-analyses and 6 RCTs of cholinesterase inhibitors generally showed small, although statistically significant, efficacy. Two RCTs of memantine also had conflicting results for treatment of neuropsychiatric symptoms. CONCLUSIONS: Pharmacological therapies are not particularly effective for management of neuropsychiatric symptoms of dementia. Of the agents reviewed, the atypical antipsychotics risperidone and olanzapine currently have the best evidence for efficacy. However, the effects are modest and further complicated by an increased risk of stroke. Additional trials of cholinesterase inhibitors enrolling patients with high levels of neuropsychiatric symptoms may be warranted.

Algorithms↗
PubMed2005

Involvement of the NMDA receptor, NO-cyclic GMP and nuclear factor K-beta in an animal model of repeated trauma.

Post-traumatic stress disorder (PTSD) may be associated with shrinkage of the hippocampus, with glutamate release causally related to these events. Recent animal studies strongly implicate activation of the nitric oxide (NO)-cascade in anxiety and stress. Using an animal model of repeated trauma, the effect of stress was investigated on the hippocampal NO-cGMP signalling pathway, specifically the release of nitrogen oxides (NOx) and its modulation by NMDA receptor-, NO-, cGMP- and nuclear factor K-beta (NFK-beta)-selective drugs. Immediately after stress, rats received the glutamate NMDA receptor antagonist, memantine (MEM; 5 mg/kg i.p./d), the NO synthase inhibitor, 7-nitroindazole sodium salt (7-NINA; 20 mg/kg i.p./d), the cGMP-specific PDE inhibitor, sildenafil (SIL; 10 mg/kg i.p./d) or the NFkappa-beta antagonist, pyrollidine dithiocarbamate (PDTC; 70 mg/kg i.p./d), for 7 days. Stress significantly increased hippocampal NOx on day 7 post-stress, which was blocked by either 7-NINA or PDTC, while MEM was without effect. SIL, however, significantly augmented stress-induced NOx accumulation. Increased cGMP therefore acts as a protagonist in driving stress-related events, while both nNOS (neuronal NOS) and iNOS (inducible/immunological NOS) may represent a therapeutic target in preventing the effects of severe stress. The value of NMDA receptor antagonism, however, appears limited in this model.

Animals↗
PubMed2005

Pharmacology and structure-activity relationships of bioactive polycyclic cage compounds: a focus on pentacycloundecane derivatives.

The chemistry of organic polycyclic cage compounds has intrigued medicinal chemists for over 50 years, yet little is published about their pharmacological profiles. Polycyclic cage compounds have important pharmaceutical applications, ranging from the symptomatic and proposed curative treatment of neurodegenerative diseases such as Parkinson's and Alzheimer's disease (e.g., amantadine and memantine), to use as anti-viral agents against influenza and the immunodeficiency virus (HIV). The polycyclic cage appears to be a useful scaffold to yield drugs with a wide scope of applications, and can be used also to modify and improve the pharmacokinetic and pharmacodynamic properties of drugs in current use. This review attempts to summarize the pharmacological profiles of polycyclic cage compounds with an emphasis on the lesser known pentacycloundecanes, homocubanes, and trishomocubanes.

Anti-Inflammatory Agents↗
PubMed1999

Regulation of calcium/calmodulin-dependent protein kinase II in the adult rat retina is mediated by ionotropic glutamate receptors.

This study is concerned with the transmitter-mediated regulation of the alpha(50 kDa) and beta(60 kDa) subunits of calcium calmodulin dependent protein kinase II (CamKII) in the adult rat retina. The level of antibody binding to the CamKII and the activity of CamKII were found to be increased after intravitreal injection of glutamate. Changes in the levels of the antibody-binding to the subunits of CamKII were observed in different subcellular fractions of the retina with a maximum response observed in crude synaptic membrane fractions. The glutamate mediated increases in CamKII were specific and blocked by 3,5-Dimethyl-1 adamantanamine; 3,5-Dimethylamantadine (Memantine), (+/-) 2-Amino-5-Phosphopentonic (AP-5) and 6-Cyano-7-Nitroquinoxaline-2,3-Dione (CNQX) but not with dl -2-Amino-3-Phosphono-Propionic (AP-3). The results indicate that the retinal neurotransmitter, glutamate, can regulate retinal CamKII activity through ionotropic but not metabotropic glutamate receptors. NMDA-receptors were found to be necessary but insufficient to stimulate CamKII. A model in which cooperative interaction between NMDA and non-NMDA glutamate receptors/ion channels is presented to explain the glutamate stimulated increases in CamKII activity in the retina.

Animals↗
PubMed2005

Excitatory amino acid neurotransmission.

In recent years great progress has been made in understanding the function of ionotropic and metabotropic glutamate receptors; their pharmacology and potential therapeutic applications. It should be stressed that there are already N-methyl-D-aspartate (NMDA) antagonists in clinical use, such as memantine, which proves the feasibility of their therapeutic potential. It seems unlikely that competitive NMDA receptor antagonists and high-affinity channel blockers will find therapeutic use due to limiting side-effects, whereas agents acting at the glycineB site, NMDA receptor subtype-selective agents and moderate-affinity channel blockers are far more promising. This is supported by the fact that there are several glycineB antagonists, NMDA moderate-affinity channel blockers and NR2B-selective agents under development. Positive and negative modulators of AMPA receptors such as the AMPAkines and 2,3-benzodiazepines also show more promise than e.g. competitive antagonists. Great progress has also been made in the field of metabotropic glutamate receptors since the discovery of novel, allosteric modulatory sites for these receptors. Selective agents acting at these transmembrane sites have been developed that are more drug-like and have a much better access to the central nervous system than their competitive counterparts. The chapter will critically review preclinical and scarce clinical experience in the development of new ionotropic and metabotropic glutamate receptor modulators according to the following scheme: rational, preclinical findings in animal models and finally clinical experience, where available.

Animals↗