TESTING A LEPTIN TESTING A LEPTIN PRODUCT AS A NOVEL PRODUCT AS A NOVEL

THERAPY FOR THERAPY FOR ALZHEIMER’S DISEASE ALZHEIMER’S DISEASE

TESTING A LEPTIN TESTING A LEPTIN PRODUCT AS A NOVEL PRODUCT AS A NOVEL

THERAPY FOR THERAPY FOR ALZHEIMER’S DISEASE ALZHEIMER’S DISEASE

J. Wesson Ashford, M.D., Ph.D. (1)J. Wesson Ashford, M.D., Ph.D. (1)

Mark A. Smith, Ph.D. (2), Mark A. Smith, Ph.D. (2),

G. Casadesus, Ph.D. (2), G. Casadesus, Ph.D. (2),

S.J. Greco, Ph.D. (3), S.J. Greco, Ph.D. (3),

J.M. Johnston, Ph.D. (3), J.M. Johnston, Ph.D. (3),

N. Tezapsidis, Ph.D. (3)N. Tezapsidis, Ph.D. (3)

     (1) Stanford /VA Aging Clinical Research Center, VAPA-(1) Stanford /VA Aging Clinical Research Center, VAPA-HCA, HCA, Palo Alto, CA USAPalo Alto, CA USA  (2) Case Western Reserve University, Cleveland, OH,   (2) Case Western Reserve University, Cleveland, OH, USAUSA  (3) Neurotez, inc., Bridgewater, NJ, USA   (3) Neurotez, inc., Bridgewater, NJ, USA

DisclosuresDisclosures

Drs. Ashford and Tezapsidis are co-principal investigators on an NIH-funded SBIR to study the effects of Leptin in Alzheimer patients

Numerous factors (particularly age and APOE) are known to moderate the course of Alzheimer’s disease (AD), but the pathophysiology of AD causation is unknown.

Serum Leptin levels appear to protect against cognitive decline in the elderly, and patients with AD have lower Leptin levels.

Leptin injections in AD-transgenic mice protect against both the development of amyloid and tau pathology and reverse the cognitive impairments found in these animals.

Therefore, Leptin may be a preventive therapy for AD

OVERVIEWOVERVIEW

Estimate MMSE as a function of time

0

5

10

15

20

25

30

-10 -8 -6 -4 -2 0 2 4 6 8 10

Estimated years into illness

MM

SE

scor

e

AAMI / MCI/ early AD -- DEMENTIA

ALZHEIMER’S DISEASE COURSE

Ashford et al., 1995

There is a prolonged period during which loss of cognitive function occurs.

Ashford et al., 1998J Neuropathol Exp Neurol.57:972

Serum Leptin levels and cognition in the elderly

6

MiId

Mod

erat

e

Nor

mal

Sev

ere

10

20

Lept

in (

ng/m

l)

Data: Satoris, Inc.

AD

In elderly, higher serum leptin appears to protect against cognitive decline (5 yr prospective study, 2,871 elders, Holden et al., 2009)

Patients with AD have lower serum leptin levels compared to controls, independent of BMI (Power et al., 2001)

In elderly, higher serum leptin appears to protect against cognitive decline (5 yr prospective study, 2,871 elders, Holden et al., 2009)

Patients with AD have lower serum leptin levels compared to controls, independent of BMI (Power et al., 2001)

7

Fewlass et al., 2004Fewlass et al., 2004

In vitro:

Leptin inhibits A production and stimulates A uptake

APP is a transmembrane protein. It is first cleaved by one of two enzymes.

Leptin receptors can activate JAK/STAT3, stimulate lipolysis, modulatng lipid raft composition, decreasing BACE activity

intracellularextra cellular

Fewlas et al., 2004

(BACE)

Lipid raft

Leptin, 4h Insulin, 4h

IC50=46.9nM IC50=13M

In vitro

Leptin is 270x more potent than Insulin in down-regulating tau phosphorylation

Greco et al., (2008) BBRC 9

Chronic s.c. Leptin in Tg2576 reduces brain A

Fewlass et al (2004) FASEB J 10

Animal studies

11

Animal studies

12

Animal behavior studies

13

Greco et al., Manuscript submittedGreco et al., Manuscript submitted

Animal behavior studies

Summary of preclinical data

14

Alzheimer’s Disease: Alzheimer’s Disease: Course, Pathology, BiomarkersCourse, Pathology, Biomarkers

Alzheimer’s Disease: Alzheimer’s Disease: Course, Pathology, BiomarkersCourse, Pathology, Biomarkers

Disease ProgressionDisease Progression

Normal tauNormal tauNormal ANormal ANormal tauNormal tauNormal ANormal A

tau?tau?AAtau?tau?AA

High tauHigh tauLow ALow AHigh tauHigh tauLow ALow A

High tauHigh tauLow ALow AHigh tauHigh tauLow ALow A

CSFCSFBiomarkersBiomarkers

NoneNoneNoneNoneAmyloidAmyloidPlaques,Plaques,

No TanglesNo Tangles

AmyloidAmyloidPlaques,Plaques,

No TanglesNo Tangles

Amyloid Amyloid PlaquesPlaques

Few TanglesFew Tangles

Amyloid Amyloid PlaquesPlaques

Few TanglesFew Tangles

AmyloidAmyloidPlaquesPlaques

Many TanglesMany Tangles

AmyloidAmyloidPlaquesPlaques

Many TanglesMany Tangles

NeuroNeuropathologypathology

NormalNormalNormalNormalPre-Pre-

SymptomaticSymptomaticADAD

Pre-Pre-SymptomaticSymptomatic

ADAD

MildMildCognitiveCognitive

ImpairmentImpairment

MildMildCognitiveCognitive

ImpairmentImpairmentADADADAD

Clinical Clinical StateState

Biomarkers for More Valid Alzheimer Diagnosis and

Precise Measurement of Severity

Biomarkers for More Valid Alzheimer Diagnosis and

Precise Measurement of Severity

Lancet Neurol 2007; 6: 734–46Lancet Neurol 2007; 6: 734–46

Potential AD BiomarkersPotential AD BiomarkersPotential AD BiomarkersPotential AD Biomarkers Blood, urine ABlood, urine Aββ40? A40? Aββ42? Neuritic 42? Neuritic

threads?threads? Most studies suggest not helpfulMost studies suggest not helpful

Protein levels in blood – Proteomics, Protein levels in blood – Proteomics, Leptin.Leptin. Lower Leptin predicts MCI progression to dementiaLower Leptin predicts MCI progression to dementia

CSF: ACSF: Aββ40? A40? Aββ42? Others A42? Others Aββ species? species? Possibly highly predictivePossibly highly predictive

CSF: tau, p-tauCSF: tau, p-tau Assess active disease progression.Assess active disease progression.

NeuroimagingNeuroimaging Structural (volumetric assessments)Structural (volumetric assessments) Functional (FDG-PET, SPECT)Functional (FDG-PET, SPECT) Specific protein imaging (PET) Specific protein imaging (PET)

0

100

200

300

400

500

600

700

AD Patients Control Patients

CSF in Alzheimer’s Disease, both MCI and Dementia

patients: Low Aβ and High Tau

CSF in Alzheimer’s Disease, both MCI and Dementia

patients: Low Aβ and High Tau

Aβ Tau

Co

nce

ntr

atio

n (

pg

/mL

)

Sunderland T, et al. JAMA. 2003;289:2094-2103.

CSF of subjects CSF of subjects with MCI with MCI progressing to AD progressing to AD has elevated tau, has elevated tau, decreased decreased ββ--amyloidamyloid

CSF of subjects CSF of subjects with MCI with MCI progressing to AD progressing to AD has elevated tau, has elevated tau, decreased decreased ββ--amyloidamyloid

The relative risk of progression to AD substantially increased in patients with MCI who had pathological concentrations of T-tau and A42 at baseline (hazard ratio 17·7, p0·0001).

The association between pathological CSF and progression to Alzheimer’s disease was much stronger than, and independent of, established risk factors including age, sex, education, APOE genotype, and plasma

homocysteine.

Hansson et al., Lancet Neurology 2006

ADNI Data – CSF ABeta, total tau

ADNI Data – CSF ABeta, total tau

100

120

140

160

180

200

220

Normal MCI Mild AD

Abe

ta(1

-42)

33

34

44

60

70

80

90

100

110

120

130

140

Normal MCI Mild AD

Tau

(tot

al)

33

34

44

Power Calculations for Reduction in Rate of Decline in AD for an Experimental

Treatment

Power Calculations for Reduction in Rate of Decline in AD for an Experimental

Treatment

ADAS-Cog 320 cases

MMSE 241 cases

hippocampal volume 21 cases

temporal horn volume 54 cases-----------------------------------------------------------------------------------------------------

CSF-tau – if level returns to normal in 12 weeks,

- then only 6 cases (3+3) needed for statistics!!

- plan 15 in each arm due to drop-outs, etc.

Neurology 2003;60:253-260

Number needed per arm for 50% effect size

(50% reduction over 1 yr in the rate of cognitive decline )

Number needed per arm for 50% effect size

(50% reduction over 1 yr in the rate of cognitive decline )

22

Numerous Leptin trials have been performed for several indications

- no safety issues -

Clinical Trials: Design

23

1

2

A focused clinical trial, in a group of 45 early-stage AD (MCI range to very mild dementia) individuals pre-screened for low leptin, elevated CSF-tau, low CSF-Awith APOE 4 genotype and MRI enrolled for a 12 week treatment period (15 on 5mg/d; 15 on 10 mg/d; 15 on placebo) with decreased CSF-tau as the primary outcome measure and cognitive function as a secondary outcome measure.

Leading to a larger, multicenter, double-blind, placebo controlled trial, for 1 year (number of patients to be determined by pilot data).

A focused clinical trial, in a group of 45 early-stage AD (MCI range to very mild dementia) individuals pre-screened for low leptin, elevated CSF-tau, low CSF-Awith APOE 4 genotype and MRI enrolled for a 12 week treatment period (15 on 5mg/d; 15 on 10 mg/d; 15 on placebo) with decreased CSF-tau as the primary outcome measure and cognitive function as a secondary outcome measure.

Leading to a larger, multicenter, double-blind, placebo controlled trial, for 1 year (number of patients to be determined by pilot data).

Summary Clinical Plan for Trial for Leptin Treatment in

AD

Summary Clinical Plan for Trial for Leptin Treatment in

AD Recruitment

Use of audience screening, genetic testing

Genetics 45 APOE 4 patients

Baseline diagnosis Amnesic MCI or mild dementia with AD

Baseline measures Elevated CSF tau, decreased A

Drug administration 3 groups - daily injections, placebo, 5, 10 mg SC

Outcome measures Primary - CSF tau Secondary – cognitive measures, other CSF/plasma measures

Slides available at:

www.medafile.com/leptin

Slides available at:

www.medafile.com/leptin