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Clinical Trials of New Drugs for Alzheimer Disease Li-Kai Huang1,2†, Shu-Ping Chao1,3† and Chaur-Jong Hu1,2,4,5*

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Clinical Trials of New Drugs for Alzheimer Disease Li-Kai Huang1,2†, Shu-Ping Chao1,3† and Chaur-Jong Hu1,2,4,5* Huang et al. Journal of Biomedical Science (2020) 27:18 https://doi.org/10.1186/s12929-019-0609-7 REVIEW Open Access Clinical trials of new drugs for Alzheimer disease Li-Kai Huang1,2†, Shu-Ping Chao1,3† and Chaur-Jong Hu1,2,4,5* Abstract Alzheimer disease (AD) accounts for 60–70% of dementia cases. Given the seriousness of the disease and continual increase in patient numbers, developing effective therapies to treat AD has become urgent. Presently, the drugs available for AD treatment, including cholinesterase inhibitors and an antagonist of the N-methyl-D-aspartate receptor, can only inhibit dementia symptoms for a limited period of time but cannot stop or reverse disease progression. On the basis of the amyloid hypothesis, many global drug companies have conducted many clinical trials on amyloid clearing therapy but without success. Thus, the amyloid hypothesis may not be completely feasible. The number of anti-amyloid trials decreased in 2019, which might be a turning point. An in-depth and comprehensive understanding of the contribution of amyloid beta and other factors of AD is crucial for developing novel pharmacotherapies. In ongoing clinical trials, researchers have developed and are testing several possible interventions aimed at various targets, including anti-amyloid and anti-tau interventions, neurotransmitter modification, anti-neuroinflammation and neuroprotection interventions, and cognitive enhancement, and interventions to relieve behavioral psychological symptoms. In this article, we present the current state of clinical trials for AD at clinicaltrials.gov.We reviewed the underlying mechanisms of these trials, tried to understand the reason why prior clinical trials failed, and analyzed the future trend of AD clinical trials. Keywords: Alzheimer disease, Clinical trials of drugs, Neuroinflammation, Neuroprotection, Anti-amyloid, Anti-tau, Cognitive enhancement Introduction many behavioral psychological symptoms of dementia The World Alzheimer Report 2015 revealed that 46.8 (BPSD) usually occur during the disease course. million people worldwide were living with dementia in Pathological evidence regarding AD shows that degen- 2015, and the total global societal cost of dementia was eration in cholinergic neuron–rich regions, namely the estimated to be US $818 billion. Alzheimer disease (AD) nucleus basalis of Meynert, frontal cortex, anterior cin- is the most common dementia type and may account for gulate cortex, and posterior cingulate cortex [2, 3], is as- 60–70% of dementia cases [1]. AD typically presents as sociated with memory loss, agitation, and apathy. progressive memory decline initially, which is accom- Acetylcholine (ACh) has been shown to be highly corre- panied or followed by other cognitive dysfunctions, such lated with memory function, including memory encoding, as visuospatial abnormalities, navigation difficulties, ex- consolidation storage, and the retrieval process [4–6]. ecutive problems, and language disturbance. These cog- Currently, at least three cholinesterase inhibitors (AChEIs) nitive impairments further affect daily life activities, and approved by the US Food and Drug Administration (FDA) are being used to treat AD, with some clinical improve- ment in cognition and global function [7]. However, * Correspondence: [email protected] †Li-Kai Huang and Shu-Ping Chao contributed equally to this work. AChEIs can only improve cognitive symptoms of AD for a 1Dementia Center, Department of Neurology, Shuang Ho Hospital, Taipei certain period but cannot modify the disease course. Medical University, New Taipei City, Taiwan The real causes of AD are still unclear. Two patho- 2The PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, National Health Research logical hallmarks of AD exist, in terms of senile plaques, Institute, Taipei, Taiwan which consist of amyloid fibrils composed of the Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Huang et al. Journal of Biomedical Science (2020) 27:18 Page 2 of 13 amyloid-beta (Aβ) peptide and neurofibrillary tangles components. In the early stages of AD, initial microglial consisting of hyperphosphorylated tau protein [8–10]. activation may serve a protective role (anti-neuroinflam- Another essential finding is brain atrophy, particularly in matory), whereby it tries to clear the amyloid and release the hippocampus [11]. The proposition that Aβ accumu- nerve growth factors. However, when Aβ or other toxic lation is the central event in AD pathogenesis was ini- products over-accumulate, proinflammatory phenotypes tially proposed by three independent groups in 1991 are activated, which damage the neurons [26]. Moreover, [12–14]. All the mutant genes of hereditary, autosomal, the inflammatory response has been observed in many and dominant familial AD, including amyloid precursor studies of postmortem tissues of patients with AD protein (APP), presenilin 1, and presenilin 2, encode the [27, 28]. Neuronal death or brain atrophy induced by major proteins involved in amyloid metabolism [14–16]. amyloid, tau, and neuroinflammation might be pre- Patients with trisomy 21 have APP gene locations with vented with neuroprotective therapies, which include more amyloid accumulation and high AD risk in late life suppressing excitable amino acid signaling pathways, because they have one more copy of the APP gene, free radical scavengers, and regeneration en- which results in increased amyloid production [17]. Pre- hancers (Table 3)[29]. In addition to potentially vious studies have shown that the cerebral deposition of disease-modifying therapies, many clinical trials focus- Aβ fibrils can occur decades before an individual shows ing on symptomatic treatment, including enhancing clinical symptoms [18]. Molecular imaging studies such cognitive functions and relieving BPSD, are on- as those using amyloid positron emission tomography going (Table 3). In summary, molecular and clinical (PET) have shown that Aβ deposition reaches a plateau events occur subsequently in the disease course of before brain atrophy can be identified from structural AD. All such events are targets of the ongoing clin- magnetic resonance imaging (MRI) and cognitive symp- ical trials of interventions for different AD stages toms [15, 19]. The amyloid hypothesis has been the (Fig. 1). The number of phase 3 trials for anti- mainstream explanation for AD pathogenesis for de- amyloid therapy decreased in 2019 (Fig. 2). The lists cades, but all the prior clinical trials involving amyloid of early-phase trials show a diverse trend (Fig. 3). burden reduction failed (Tables 1and 2). Tau accumulation, which might be a consequence of Anti-amyloid therapy neuronal damage, was proposed to begin between AD A few approaches reduce the amyloid burden have been clinical symptom development and Aβ accumulation developed. Aβ is produced from APP, which is digested [20]. Neurofibrillary tangles and quantitative neuronal by gamma-secretase and beta-secretase [30–32]. Both loss, but not amyloid plaques, have been found to correl- gamma-secretase and beta-secretase inhibitors have been ate with disease severity and dementia duration [21–23]. the targets of new drug development [33, 34]. Aβ is de- Moreover, PET studies have shown that the spatial pat- graded by a few enzymes, including neprilysin, and has terns of tau tracer binding are closely linked to neurode- also been considered for new drug development [35, 36]. generation patterns and the clinical presentation in Removing Aβ through immunotherapy is also a reason- patients with AD [24]. Recently, biomarkers of amyloid, able strategy. tau, and neurodegeneration were used for precisely diag- In 2019, nine phase 3 trials for eight drugs targeting nosing AD [25]. amyloid are underway. Two of these enrolled patients Furthermore, the brains of patients with AD exhibited with preclinical AD; one trial required positive amyloid evidence of sustained inflammation. Aβ itself acts as a PET, and the other required genetic mutation or strong proinflammatory agent, activating many inflammatory genetic risks. Four trials enrolled patients with Table 1 Failed phase 3 trials on anti-amyloid therapy in AD since 2016 Year Drug Mechanism of action Participants Main reasons for failure Remarks 2016 Solanezumab Monoclonal antibody Mild AD Lack of efficacy Solanezumab Monoclonal antibody Prodromal AD Strategic Verubecestat BACE inhibitor Mild to moderate AD Lack of efficacy 2018 Verubecestat BACE inhibitor Prodromal AD Lack of efficacy Worsens cognition Atabecestat BACE inhibitor Preclinical AD Toxicity Worsens cognition Lanabecestat BACE inhibitor Early AD Lack of efficacy Worsens cognition Lanabecestat BACE inhibitor Mild AD Lack of efficacy Worsens cognition 2019 Aducanumab Monoclonal antibody Early AD Lack of efficacy CNP520 BACE inhibitor Preclinical AD Lack of efficacy Worsens cognition
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