Drug Discovery Opinion

Following from positive phase II results, the announcement earlier this year that Dimebon (latrepirdine) failed to show a significant effect in a phase III clinical trial in Alzheimer’s patients was a major blow to patients, families and doctors. A study by researchers at UT Southwestern Medical Center has now shown that Dimebon can increase neurogenesis in adult rodent brains and have identified other, more potent compounds.

An in vivo screen of 1000 small molecules in adult mice identified eight compounds that were able to enhance neuron formation in the subgranular zone of the hippocampal dentate gyrus. One of the compounds, P7C3, was selected for further study on the basis of favourable ADME predictions. Daily administration of P7C3 to aged rats for 7 days was shown to enhance hippocampal neurogenesis relative to control animals and, after 2 months, treated rats performed significantly better in the Morris water maze test which provides a measure of learning and memory.

P7C3 exerts its proneurogenic effects by protecting newborn neurons from apoptosis and the team next compared the activity of P7C3 with that of Dimebon, which is also believed to have anti-apoptotic activity. Dimebon was found to be proneurogenic in vivo, albeit at levels 10-30 times higher than P7C3, raising the possibility that the two compounds may share a common mechanistic pathway. Although this idea can only be rigorously tested after identification of the molecular target(s), the study raises the hope that more potent analogues of Dimebon with improved clinical efficacy could be identified and also provides appropriate assays.

The study is published in the journal Cell.

Results from a phase II trial of the experimental drug Dimebon (latrepirdine) in people with Huntington’s disease have provided indications that it may improve cognition. The drug, being developed by Medivation, Inc., is also in Phase III trials for Alzheimer’s disease. In July 2009, Medivation and Pfizer, Inc. launched a Phase III clinical trial (HORIZON) of the drug for Huntington’s disease.

Huntington’s disease is a progressive neurodegenerative disorder that impacts movement, behaviour and cognition, generally resulting in death within 20 years of the disease’s onset. The disease steadily erodes memory and ability to think and learn. Over time, this cognitive impairment contributes to the loss of the ability to work and perform the activities of daily life. There are no treatments current available that effectively alter the course of the disease or improve cognition.

We have previously reported on the potential for Dimebon in Alzheimer’s disease (July 2008, July 2009), where the ability of the drug to stabilise and/or enhance mitochondrial function is believed to be of benefit. Mitochondria are also thought to play a role in the development of Huntington’s disease, suggesting that Dimebon could also have utility in this condition.

Karl Kieburtz, M.D., University of Rochester Medical Center neurologist and lead investigator on the Horizon trial, said:

“This is the first clinical trial that has focused on what is perhaps the most disabling aspect of the disease. While more investigation needs to be done, these results are encouraging and show, for the first time, a statistically significant benefit in terms of improved cognitive function in patients with Huntington’s disease.”

In the phase II study, the impact of the drug on 91 patients over a 90 day period was assessed. Half were given the drug and the other half a placebo. The patients were then evaluated using a cognitive tool called the Mini-Mental State Examination. This test – which is used by clinicians to evaluate the stage and severity of dementia and Alzheimer’s disease – consists of questions used to evaluate an individual’s orientation, memory, and ability to follow commands. The researchers found that the drug on average improved the scores of people taking the drug compared to those who received the placebo. Although the treatment had no significant impact on the Unified Huntington’s Disease Rating Scale (UHDRS) or the Alzheimer Disease Assessment Scale–cognitive subscale (ADAS-cog), the results support further investigation in Huntington’s disease.

Results of the study are published in the Archives of Neurology.

Although not without opponents – and still unproven – the theory that reducing levels of β-amyloid peptides will lessen neuronal damage and cognitive deficits remains a central tenet of Alzheimer’s disease research and the focus of many pharmaceutical companies. Last week, however, it was reported at the Alzheimer’s Association annual meeting in Vienna that Dimebon^® (latrepirdine), a drug which has shown clinical benefit in people with mild to moderate Alzheimer’s disease, increases levels of β-amyloid in the releasate from isolated nerve terminals and in the interstitial fluid from the brains of transgenic mice bred to model Alzheimer’s disease. This unexpected result raises questions about how Dimebon^® works and also, perhaps, about the validity of the ‘amyloid hypothesis’. One possibility is that the neuroprotective effects of Dimebon^® are sufficient to outweigh the adverse effects of increased concentrations of β-amyloid. Preclinical studies have suggested that Dimebon^® could prevent neuronal damage and dysfunction by stabilising or improving mitochondrial function. In addition, biochemical studies have shown effects on α-adrenergic receptors, histamine receptors and serotonin receptors as well as on Ca²⁺ flux and apoptosis. Alternatively, Dimebon^® could cause an acute increase in amyloid levels, but lower levels on chronic dosing, or it could play a role in amyloid transport. Whatever the explanation for the present results, further investigations into the mechanism of action of Dimebon® and the relevance of animal models of acute amyloid lowering to human disease are of key importance.

Dimebon^®, which has been used in Russia to treat hayfever since the 1980s, is being jointly developed by Medivation and Pfizer and is currently in phase III clinical trials.

A study published in the July 18th issue of The Lancet shows that a drug once used in Russia to treat hayfever has the potential to improve symptoms in dementia patients. The study of 183 patients, tested dimebon (dimebolin) vs placebo in patients with untreated mild-to-moderate dementia. Patients taking dimebon improved over a six month period whilst those taking placebo got worse.
A smaller group of patients who continued taking dimebon for a further six months showed continuing improvement over this period. This ongoing improvement is seen as particularly important since none of the approved drugs for Alzheimer’s Disease has shown increasing improvement over twelve months. Although this was a relatively small study, the initial results are very encouraging and warrant further investigation.

In a separate study, also reported in The Lancet, immunisation against the amyloid-beta peptide was shown to clear amyloid plaques from the brain, but not to prevent the progressive neurodegeneration associated with Alzheimer’s disease.