Lithium delays progression of amyotrophic

lateral sclerosis

Francesco Fornai*†‡, Patrizia Longone§, Luisa Cafaro†, Olga Kastsiuchenka*, Michela Ferrucci*, Maria Laura Manca¶,Gloria Lazzeri*, Alida Spalloni§, Natascia Bellio, Paola Lenzi*, Nicola Modugno†, Gabriele Siciliano¶, Ciro Isidoro,Luigi Murri¶, Stefano Ruggieri†, and Antonio Paparelli**Department of Human Morphology and Applied Biology, and ¶Department of Neuroscience, Clinical Neurology, University of Pisa 56100 Pisa, Italy;

PNAS February 12, 2008 vol. 105 no. 6 2055

ALS is a devastating neurodegenerative illness with no effective treatment

Survival rates of 3-5 yrs from disease onset(11months for bulbar forms)

90% sporadic 10% FALS

Cu/Zn superoxide dismutase (SOD1)

• Transgenic mice-SOD mutation similar phenotype as ALS

• Motorneurons, interneurons, glial cells

• Lithium-mood stabiliser, neuropotective in animal model-brain ischemia, kainate toxicity, promotes autophagy through IMP1

• Autophagy- keyrole in neurodegeneration

• Study proposed to test neuro protective effect of lithium in transgenic mice G93A ALS models

• Based on promising results, a clinical trial was also conducted

Study 1

• In vivo

• Control miceWT,G93A mice

• Breeding protocol

• Treatment saline/lithium

• Tissue preparation,Electron microscopy

• In vitro-Primary neuronal cultures,immunocytochemistry,cell lines

Effect of lithium on disease duration and survival in mice

• Mean survival time110.8 to 148 days

• Disease duration 9days to >38 days

• Delayed onset of paralysis and motor deficits

Effects of lithium treatment on the lifespan and neurological symptoms of G93A mice

Fornai F. et.al. PNAS;2008;105:2052-2057

©2008 by National Academy of Sciences

• Effect on motor neuron survival(lamina1X of lumbar, cervical spinal cord and brainstem motor nuclei)

• Preservation of size and number of motor neuron

• Decreased astrocytosis

• Increased lamina vii interneuron number

Neuroprotective effects of lithium on medium-size lamina VII neurons

Fornai F. et.al. PNAS;2008;105:2052-2057

©2008 by National Academy of Sciences

• Lithium treatment rescues spinalcord mitochondria and facilitates clearance of alpha synuclein,ubiquitin and SOD1

• Increases the number and normalises size of mitochondria

Effects of lithium administration on motor neurons mitochondria in vivo

Fornai F. et.al. PNAS;2008;105:2052-2057

©2008 by National Academy of Sciences

• Lithium increases the number of autophagic vacuoles both in vitro and in vivo.

• Decreased Autophagy is postulated mechanism in neurodegeneration

Effects of lithium on autophagy in vivo and in vitro

Fornai F. et.al. PNAS;2008;105:2052-2057

©2008 by National Academy of Sciences

Study 2-clinical trial

• 15 month

• Parallel randomized study

• IRCSS ethical comitee

• Informed consent

• Statistical significance required minimum 40 patients

• N=44 male-20.female-24

• El escorial diagnostic criterian

• Disease duration<5 years

• No familial case

• 33 patients classical onset,11 presented with bulbar symptoms

• groupA-16 patients(M-8,F-8),4 of them had bulbar

• Riluzole 100mg/day +lithium carbonate 300mg/day

• groupB-38(m-12,f-16),7 of them had bulbar

• Riluzole only

• Treating physician-not blind, administers and monitors lithium concentration and adjusts to 0.4-0.8meq/l

• Evaluating physician-clinical evaluation, measurement of FVC, data analysis

• Compliance and adverse effects were monitored through out the study period

• Asessment 6 times,at baseline and every 3 months until 15months

• Primary end point-survival rate

• Secondary outcome- change in global function, ALSFRS-R(n-48) &Norris ALS scale(n-100) ,(functioning of upper and lower limbs, bulbar function)

• Quality of life SF-36

• Objective measures-MRC & FVC

• ANOVA

• Kolmogorov-sminrnov

• Kaplameier curves

• Unpaired t test

results

• Demographic variables and baseline ratings are well distributed among study and control groups

• All patients treated with lithium were alive at the end of the study vs 30% mortality in riluzole only group

• FVC did not progress significantly(89…75)• No significant decrement in short form health

survey-sf 36 scale• MRC progressed ony at end of the follow

up(138.5…113.4)

• In riluzole only group,Norris scale significantly decreased (86.6…..55.3)

• ALSFRS score significantly decreased(40.2….24.2)

• FVC significantly decreased(91…..58)

• MRC scale from 140…..92

• At the end of the follow up,mean decrement in in Norris score was 46.1% in riluzole only group vs 10.6% in lithium group.

• ALSFRS was 39.8% vs 14.35

• MRC..34.6% decrease in riluzole group vs 18% in lithium group.

Effects of lithium treatment on disease symptom progression and survival in patients with ALS

Fornai F. et.al. PNAS;2008;105:2052-2057

©2008 by National Academy of Sciences

conclusion

• This study indicates that lithium delays progression in human patients.

• All persons on lithium were alive at the end of the study

• MRC-minimal progression and FVC –preservation

• Lithium affects multiple targets

•Thank you