U.S. patent application number 16/414878 was filed with the patent office on 2019-11-21 for methods and compositions for treatment of alzheimer's disease.
The applicant listed for this patent is Neurotrope Bioscience, Inc.. Invention is credited to Daniel L. Alkon.
Application Number | 20190350898 16/414878 |
Document ID | / |
Family ID | 66691034 |
Filed Date | 2019-11-21 |
United States Patent
Application |
20190350898 |
Kind Code |
A1 |
Alkon; Daniel L. |
November 21, 2019 |
METHODS AND COMPOSITIONS FOR TREATMENT OF ALZHEIMER'S DISEASE
Abstract
A method for treating Alzheimer's disease (AD) by administering
to an AD patient a PKC activator, such as a bryostatin-1, without
administering a NMDA receptor antagonist, such as memantine.
Inventors: |
Alkon; Daniel L.; (Chevy
Chase, MD) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Neurotrope Bioscience, Inc. |
New York |
NY |
US |
|
|
Family ID: |
66691034 |
Appl. No.: |
16/414878 |
Filed: |
May 17, 2019 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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62673590 |
May 18, 2018 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 31/365 20130101;
A61P 25/28 20180101 |
International
Class: |
A61K 31/365 20060101
A61K031/365; A61P 25/28 20060101 A61P025/28 |
Claims
1. A method of treating Alzheimer's disease comprising
administering to a patient in need thereof a pharmaceutically
effective amount of bryostatin-1, wherein the patient is not
administered a NMDA receptor antagonist.
2. The method of claim 1 wherein the NMDA receptor antagonist is
memantine.
3. The method of claim 1 wherein the patient is diagnosed with
moderate Alzheimer's disease.
4. The method of claim 1 wherein the patient is diagnosed with
moderate to severe Alzheimer's disease.
5. The method of claim 1 wherein the patient is administered less
than 40 mcg bryostatin-1.
6. The method of claim 1 wherein the patient is administered about
15 mcg to about 25 mcg bryostatin-1.
7. The method of claim 1 wherein the patient is administered about
20 mcg bryostatin-1.
8. A method of treating Alzheimer's disease comprising
administering to a patient in need thereof a pharmaceutically
effective amount of bryostatin-1, wherein the treatment excludes
administration of a NMDA receptor antagonist.
9. The method of claim 8 wherein the NMDA receptor antagonist is
memantine.
10. The method of claim 8 wherein the patient is diagnosed with
moderate Alzheimer's disease.
11. The method of claim 8 wherein the patient is diagnosed with
moderate to severe Alzheimer's disease.
12. The method of claim 8 wherein the patient is administered less
than 40 mcg bryostatin-1.
13. The method of claim 8 wherein the patient is administered about
15 mcg to about 25 mcg bryostatin-1.
14. The method of claim 8 wherein the patient is administered about
20 mcg bryostatin-1.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims priority from U.S. Provisional
Application No. 62/673,590, filed May 18, 2018, which is herein
incorporated by reference in its entirety.
BACKGROUND
[0002] All references cited herein are expressly incorporated by
reference.
[0003] Treatments of Alzheimer's disease (AD) have been based on
immunotherapy for pathologic hallmarks of the autopsy AD brain,
amyloid plaques and neurofibrillary tangles generated by
hyperphosphorylated tau protein. Other therapeutic strategies have
focused on enhancement or blockade of neurotransmitters at synaptic
junctions (Reisberg et al. N Engl J Med. 2003 Apr. 3;
348(14):1333-41). While the latter have generated drugs with some
symptomatic efficacy, the approved drugs have thus far not been
effective in preventing, improving, and/or reversing the
progressive neurodegeneration that ultimately causes major
cognitive dysfunction and functional decline in AD patients (Farlow
et al., Clin. Ther. 2010 July; 32(7):1234-51. doi: 10.1016; Farlow
et al., BMC Neurology 2011 vol. II, article 57; and Farlow,
Neurology 2005 65:S1-S4). This lack of efficacy is likely related
to the lack of close correlation demonstrated by plaques and
tangles with the degree of cognitive deficits.
[0004] On the other hand, cognitive deficits have been shown to
correlate closely with the loss of synapses as measured directly or
indirectly at autopsy (Terry et al., Ann Neurol. 1991 October;
30(4):572-80). An effective therapeutic for AD should be directed
toward, not only the causes, but also the consequences of the
characteristic progressive neurodegeneration. Based on the synaptic
loss in AD, there would be a significant benefit in a therapeutic
strategy that can restore lost synapses in AD brains.
SUMMARY
[0005] Methods of treating Alzheimer's disease (AD) are described
herein including administering to an AD patient in need thereof a
protein kinase C (PKC) activator, wherein the patient is not
administered an NMDA receptor antagonist. In embodiments, the PKC
activator is bryostatin or analog thereof. In embodiments, the PKC
activator is bryostatin-1.
[0006] Methods of treating Alzheimer's disease are also described
herein including administering to an AD patient in need thereof a
PKC activator, wherein the treatment excludes administration of a
NMDA receptor antagonist. In embodiments, the PKC activator is
bryostatin or analog thereof. In embodiments, the PKC activator is
bryostatin-1.
[0007] Methods of treating Alzheimer's disease are also described
herein including administering to an AD patient in need thereof
bryostatin-1 wherein the patient is not also administered
memantine.
[0008] Methods of treating Alzheimer's disease are also described
herein including administering to an AD patient in need thereof no
more than or less than about 30, 35, or 40 mcg (or range therein)
of bryostatin-1 wherein the patient is not also administered
memantine. In embodiments, the patient is administered less than 40
mcg bryostatin-1. In some embodiments the patient is administered
about 20 mcg bryostatin-1.
[0009] Methods of treating Alzheimer's disease are also described
herein including administering to an AD patient in need thereof
about 20 mcg or 25 mcg (or range therein) of bryostatin-1 wherein
the treatment excludes memantine.
[0010] Methods of treating Alzheimer's disease are also described
herein including administering to an AD patient in need thereof no
more than or less than about 30, 35, or 40 mcg (or range therein)
of bryostatin-1 wherein the patient is not receiving memantine
treatment. In some embodiments the patient is administered 15-40
mcg bryostatin-1. In other embodiments, the patient is administered
less than 40 mcg bryostatin-1
[0011] Methods of treating Alzheimer's disease are also described
herein including administering to an AD patient in need thereof
about 20 mcg or 25 mcg (or range therein) of bryostatin-1 wherein
the patient is not receiving memantine treatment. In some
embodiments the patient is administered about 20 mcg
bryostatin-1.
[0012] Methods of treating Alzheimer's disease are also described
herein including administering to an AD patient in need thereof
about 15 mcg to about 25 mcg (or range therein) of bryostatin-1
wherein the treatment excludes memantine and provides cognitive
improvement. In some embodiments the patient is administered about
20 mcg bryostatin-1.
[0013] Methods of treating Alzheimer's disease are also described
herein including administering to a patient in need thereof about
20 mcg or 25 mcg (or range therein) of bryostatin-1 wherein the
treatment excludes memantine and is provided for at least or more
than 4, 5, or 6 weeks.
[0014] Each of the methods described herein may further include the
administration of a compound selected from the group consisting of
galantamine, donepezil, rivastigimine, physostigmine, tacrine,
huperzine A, ladostigil, and combinations thereof.
[0015] In some embodiments, the patient in need of treatment is a
patient diagnosed with mild Alzheimer's disease. In other
embodiments, the patient is diagnosed with mild to moderate
Alzheimer's disease.
[0016] In some embodiments, the patient in need of treatment is a
patient diagnosed with moderate Alzheimer's disease. In other
embodiments, the patient is diagnosed with moderate to severe
Alzheimer's disease. In other embodiments, the patient in need of
treatment is a patient diagnosed with severe Alzheimer's
disease.
[0017] In some embodiments, the patient is diagnosed with early
onset Alzheimer's disease. In other embodiments, the patient is
diagnosed with late onset Alzheimer's disease.
[0018] Compositions for treating Alzheimer's Disease are also
described herein and include at least one PKC activator, the
composition being free of any NMDA receptor antagonist. In some
embodiments, the PKC activator is bryostatin or an analogue
thereof. In particular embodiments, the PKC activator is
bryostatin-1. In embodiments, the compositions are free of
memantine.
BRIEF DESCRIPTION OF THE DRAWINGS
[0019] The patent or application contains at least one drawing
executed in color. Copies of this patent or patent application
publication with color drawing(s) will be provided by the Patent
and Trademark Office upon request and payment of the necessary
fee.
[0020] Some specific embodiments of the disclosure may be
understood by referring, in part, to the following description and
the accompanying drawings.
[0021] FIG. 1 includes graphs showing the SIB change from baseline
compared to placebo for the modified intent-to-treat (mITT)
population and also the Completers population treated with
Bryostatin.
[0022] FIG. 2 is a graph showing the SIB change from baseline
compared to placebo 30 days post dosing in the mITT population.
[0023] FIG. 3 is a graph showing the SIB change from baseline
compared to placebo 30 days post dosing in the Completers
population.
[0024] FIG. 4 includes graphs showing the SIB change from baseline
compared to placebo for the mITT population treated with bryostatin
with or without memantine.
[0025] FIG. 5 includes graphs showing the SIB change from baseline
compared to placebo for the Completers population treated with
bryostatin with or without memantine.
[0026] FIG. 6 includes graphs showing the ADCS-ADL-SIV efficacy in
the mITT population and the Completers population.
[0027] FIG. 7 includes graphs showing the sustained improvement of
the SIB versus baseline and placebo 30 days post dosing in the
Completers population.
[0028] FIG. 8 is a graph showing the Body Surface Area analysis of
a bryostatin dose.
DETAILED DESCRIPTION
[0029] In general, the present disclosure provides methods for
treating Alzheimer's disease using PKC activators in the absence of
any NMDA receptor antagonist, such as memantine. As used herein,
the term "protein kinase C activator" (i.e., "PKC activator")
refers to a substance that increases the rate of the reaction
catalyzed by protein kinase C, upregulates the expression of PKC
(e.g., upregulates the expression of PKC.alpha., PKC .beta.II, PKC
.gamma. and/or PKC .epsilon.), or otherwise facilitates the
activation of PKC. In certain embodiments, the PKC activator may be
any of bryostatins 1-20, a bryolog, neristatin, a polyunsaturated
fatty acid, or a combination of two or more of any of the foregoing
substances.
[0030] As used herein, the term "NMDA receptor antagonist" refers
to a substance that antagonizes (i.e., inhibits) the action of NMDA
receptors. Some examples of NMDA receptor antagonists include
memantine, drug combinations containing memantine,
dextromethorphan, ketamine, phencyclidine (PCP), methoxetamine
(MXE), and nitrous oxide (N.sub.2O). Any one or all of the
foregoing NMDA receptor antagonists may be excluded from the method
of treating AD.
[0031] In certain embodiments, the present disclosure provides
methods comprising administering to a human subject with
Alzheimer's disease a pharmaceutically effective amount of a PKC
activator without administering any NMDA receptor antagonist, such
as memantine. The PKC activator may be administered as part of a
composition suitable for administration to a human subject. The
compositions used in the methods of the present disclosure may be
administered via any suitable route, such as, for example, orally,
intraperitoneally, subcutaneously, intranasally, buccally,
trans-dermally intramuscularly, intrarectally, intravenously, or by
oral inhalation.
[0032] In some embodiments, the present disclosure provides methods
comprising administering to a human subject with Alzheimer's
disease a composition consisting essentially of, or containing
exclusively, a pharmaceutically effective amount of a PKC activator
in a pharmaceutically suitable carrier, optionally along with one
or more pharmaceutically inactive auxiliary agents. Thus, the
composition preferably does not include a second active agent,
particularly a NMDA receptor antagonist. Compositions and methods
consisting essentially of a PKC activator exclude additional active
compounds, such as memantine.
[0033] Bryostatins, in particular, may be used as a PKC activator
in the methods of the present disclosure. The term "bryostatins" is
herein meant to also include the numerous known analogues thereof,
unless otherwise specified. The bryostatins are a family of
naturally occurring macrocyclic compounds originally isolated from
marine bryozoa. Currently, there are about 20 known natural
bryostatins which share three six-membered rings designated A, B
and C, and which differ mainly in the nature of their substituents
at C7 (OR.sup.A) and C20 (R.sup.B). A representative generic
structure of the bryostatins is provided below:
##STR00001##
[0034] Bryostatin 1 and analogues (derivatives) of bryostatin 1 are
described in U.S. Pat. No. 4,560,774, the contents of which are
herein incorporated by reference in their entirety. Some examples
of bryostatins that may be used as a PKC activator in methods of
the present disclosure include bryostatin 1, bryostatin 2,
bryostatin 3, bryostatin 4, bryostatin 5, bryostatin 6, bryostatin
7, bryostatin 8, bryostatin 9, bryostatin 10, bryostatin 11,
bryostatin 12, bryostatin 13, bryostatin 14, bryostatin 15,
bryostatin 16, bryostatin 17 bryostatin 18, bryostatin 19, and
bryostatin 20.
[0035] Analogues of bryostatins, commonly referred to as bryologs,
may or may not be used in the methods of the present disclosure.
Bryologs are structural analogues of bryostatin. While bryostatin
has two pyran rings and one 6-membered cyclic acetal, in most
bryologs one of the pyrans of bryostatin is replaced with a second
6-membered acetal ring. This modification reduces the stability of
bryologs, relative to bryostatin, for example, in both strong acid
or base, but has little significance at physiological pH. Bryologs
also have a lower molecular weight (ranging from about 600 to 755),
as compared to bryostatin (988), a property which may facilitate
transport across the blood-brain barrier. Examples of suitable
bryologs include, but are not limited to analogs and derivatives of
bryostatins, such as those described in U.S. Pat. Nos. 6,624,189,
7,256,286 and 8,497,385, the disclosures of which are incorporated
herein by reference in their entirety.
[0036] Another example of suitable PKC activators include potassium
channel activators, such as, for example, diazoxide. In certain
embodiments, neristatins, such as neristatin 1, may be used in the
methods of the present disclosure for treating Alzheimer's disease.
Other suitable PKC activators include, but are not limited to,
phorbol-12-myristate-13-acetate (PMA), okadaic acid,
1.alpha.,25-dihydroxyvitamin D3, 12-deoxyphorbol-13-acetate
(prostratin), 1,2-dioctanoyl-sn-glycerol (DOG),
1-oleoyl-2-acetyl-sn-glycerol (OAG),
(2S,5S)-(E,E)-8-(5-(4-(trifluoromethyl)phenyl)-2,4-pentadienoylamino)benz-
olactam (.alpha.-amyloid precursor protein modulator),
cis-9-octadecenoic acid (oleic acid), ingenol 3-angelate,
resiniferatoxin,
L-.alpha.-Phosphatidyl-D-myo-inositol-4,5-bisphosphate, triammonium
salt (PIP2), phorbol-12,13-dibutyrate,
8(S-hydroxy-(5Z,9E,11Z,14Z)-eicosatetraenoic acid (8(S)-HETE),
12.beta.-[(E,E)-5-Phenyl-2,4-pentadienoyloxy]daphnetoxin
(merzerein), clomiphene citrate, sodium oleate, phorbol
12,13-diacetate, phorbol-12,13-didecanoate,
1,2-dipalmitoyl-sn-glycerol, 1-Stearoyl-2-linoleoyl-sn-glycerol,
phorbol-12,13-didecanoate, 1,2-dipalmitoyl-sn-glycerol,
1-stearoyl-2-linoleoyl-sn-glycerol, phorbol 12,13-dihexanoate,
prostratin and its analogs, resiniferonol
9,13,14-ortho-phenylacetate, C-8 ceramide,
1,6-bis(Cyclohexyloximinocarbonylamino)hexane;
1,6-Di(O-(carbamoyl)cyclohexanone oxime)hexane (RHC-80267),
(+/-)-1-oleoyl-2-acetylglycerol, 5(S),6(R),15(S)-TriHETE (Lipoxin
A4), (-)-Indolactam V. SC-9, SC-10, zoledronic acid monohydrate,
12-deoxyphorbo 13-angelate 20-acetate,
6-(N-decylamino)-4-hydroxymethylindole, 4.alpha.-phorbol
12,13-dibutyrate, 1,2-dihexanoyl-sn-glycerol, zoledronic acid
disodium salt tetrahydrate, arachidonic acid methyl ester,
arachidonic acid-d8. In some embodiments, any of the above
bryologs, potassium channel activators, or neristatins may be
excluded from the method. Alternatively, in some embodiments, any
of the above bryologs, potassium channel activators, or neristatins
may be used in combination with one or more bryostatins in the
method described above.
[0037] As used herein, "a pharmaceutically effective amount" is an
amount of a pharmaceutical compound or composition having a
therapeutically relevant effect on Alzheimer's disease. A
therapeutically relevant effect typically relates to or is
evidenced by at least some improvement in a biomechanical process
(e.g., gait, use of limbs, and the like) or a change in the
cellular, physiological or biochemical parameters associated with
any of the causes of Alzheimer's disease. A therapeutically
relevant effect may also be evident in an improved cognitive
ability, such as short-term memory or problem solving.
[0038] The PKC activator is typically within a pharmaceutically
acceptable carrier (i.e., diluent) when administered. As used
herein, and as generally understood in the pharmaceutical arts, the
term "pharmaceutically acceptable" generally refers to those
compounds, materials, compositions, and/or dosage forms that are,
within the scope of sound medical judgment, suitable for entering a
living organism or living biological tissue, preferably without
significant toxicity, irritation, or allergic response. The
pharmaceutical compositions of the present invention may be
formulated for administration in liquid or solid form. In the
pharmaceutical composition, the compound is generally dispersed in
the physiologically acceptable carrier, by being dissolved or
emulsified in a liquid carrier, or mixed (i.e., blended or
compounded) with a solid carrier. The carrier should be compatible
with other ingredients of the formulation and physiologically safe
to the subject. Examples of suitable aqueous and non-aqueous
carriers that may be employed in the pharmaceutical compositions of
the invention include, for example, water, ethanol, polyols (such
as glycerol, propylene glycol, polyethylene glycol, and the like),
vegetable oils (such as olive oil), injectable organic esters (such
as ethyl oleate), and suitable mixtures thereof. In different
embodiments, the pharmaceutical formulation may be formulated for
oral administration (e.g., as tablets, capsules, powders, granules,
pastes, solutions, suspensions, drenches, or syrups); parenteral
administration (e.g., by subcutaneous, intramuscular or intravenous
injection as provided by, for example, a sterile solution or
suspension); sublingual or buccal administration; transdermal
administration; or nasal administration. The pharmaceutical
composition may also include one or more pharmaceutically inactive
auxiliary agents, such as pH buffering agents; sugars (e.g.,
lactose, glucose, sucrose, and oligosaccharides, such as sucrose,
trehalose, lactose, or dextran); antimicrobials; and/or sweetening,
flavoring, or coloring agents.
[0039] In certain embodiments, a pharmaceutically effective amount
for bryostatins and/or bryologs may be from about 0.0000001 to
about 5.00 mcg per kg host body weight per day, which can be
administered in single or multiple doses. In some embodiments, the
dosage level may be: from about 0.0000001 mcg/kg to about 2.50
mcg/kg per day; from about 0.0000005 mcg/kg to about 1.00 mcg/kg
per day; from at least about 0.0000001 mcg/kg to about 2.50 mcg/kg
per day; from at least about 0.00000005 mcg/kg to about 1.00 mcg/kg
per day; from at least about 0.000001 mcg/kg to about 5.0 mcg/kg
per day; or from about 0.00001 mcg/kg to about 5.0 mcg/kg per dose.
In other embodiments, the dosage may be about 0.00000001 mcg/kg to
about 0.00005 mcg/kg; 0.00005 mcg/kg to about 0.05 mcg/kg; about
0.0005 mcg/kg to about 5.0 mcg/kg per day; about 0.0001 mcg/kg to
about 0.5 mcg/kg per dose; or 0.001 to 0.25 mcg/kg per dose.
[0040] In some embodiments, a pharmaceutically effective amount of
a PKC activator may be an amount ranging from about 1 mcg to about
500 meg per dose, or more particularly, from about 5 mcg to about
200 mcg per dose, or more particularly, from about 10 mcg to about
100 mcg per dose, or more particularly, from about 20 mcg to about
40 meg per dose. In different embodiments, the PKC activator is
administered in an amount of precisely or about 10, 15, 20, 25, 30,
35, 40, 45, or 50 mcg, or in an amount within a range bounded by
any two of the foregoing values, wherein the term "about" generally
indicates no more than .+-.10% or .+-.5% from a given value.
[0041] In some embodiments, the dosing is from about 1 .mu.g/kg
(3-25 .mu.g/.sup.m2) to 120 .mu.g/kg (360-3000 .mu.g/m.sup.2). In
other embodiments, the dosing is from about 0.04-0.3 .mu.g/kg (1
.mu.g/m.sup.2) to about 1-10 .mu.g/kg (25 .mu.g/m.sup.2). In other
embodiments, the dosing is from about 0.01 .mu.g/m.sup.2 to about
25 .mu.g/m.sup.2. In other embodiments, the dosing is from about
0.0002-0.0004 .mu.g/kg to about 0.05-1 .mu.g/kg.
[0042] In some embodiments, the PKC activator is a bryostatin or
analogue thereof and a pharmaceutically effective amount of the
bryostatin or analogue thereof may be an amount ranging from about
1 mcg to about 500 mcg per dose, or more particularly, from about 5
mcg to about 200 mcg per dose, or more particularly, from about 10
mcg to about 100 mcg per dose, or more particularly, from about 20
mcg to about 40 mcg per dose. In some embodiments, the PKC
activator is a bryostatin or analogue thereof administered at a
dosage of about 0.001 to 100 mcg/kg; 0.01 to about 50 mcg/kg, about
0.1 to about 10 mcg/kg.
[0043] In some embodiments, the PKC activator is a bryostatin or
bryolog, and the bryostatin or bryolog is used (administered) in an
amount from about 0.0001 to about 1000 micrograms. In some
embodiments, the bryostatin or bryolog is used in an amount of at
least or about 0.0001, 0.0005, 0.001, 0.002, 0.003, 0.004, 0.005,
0.006, 0.007, 0.008, 0.009, 0.01, 0.02, 0.03, 0.04, 0.05, 0.06,
0.07, 0.08, 0.09, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0,
5.0, 10.0, 15.0, 20.0, 25.0, 50.0, 75.0, 100.0, 150.0, 200.0,
250.0, 300.0, 400.0, 500.0, 600.0, 750.0, 800.0, 900.0, or 1000.0
micrograms, or an amount within a range bounded by any two of the
foregoing values.
[0044] In some embodiments, the PKC activator present in the
compositions used in the methods of the present disclosure is a
bryostatin or bryolog, and the bryostatin or bryolog is used
(administered) in an amount of less that 50 micrograms (i.e., 50
mcg, or 50 .mu.g). In some embodiments, the bryostatin or bryolog
is used in an amount of less than 45 mcg. In some embodiments, the
bryostatin or bryolog is used in an amount of less than 40 mcg (40
.mu.g). In other embodiments, the bryostatin or bryolog is used in
an amount of less than 30 meg (.mu.g). In further embodiments to
any of the foregoing embodiments, a lower limit of at least or
above 1, 2, 3, 4, 5, 10, 15, 20, or 25 mcg may be used.
[0045] In some embodiments, the pharmaceutical composition will
include bryostatin (e.g., bryostatin-1) in an amount of 0.1 mcg to
50 mcg, 0.1 mcg to 25 mcg, 0.1 mcg to 20 mcg, 0.1 mcg to 15 mcg,
0.5 mcg to 50 mcg, 0.5 mcg to 25 mcg, 0.5 mcg to 20 mcg, 0.5 to 15
mcg, 1 mcg to 50 mcg, 1 mcg to 25 mcg, 1 mcg to 20 mcg, 1 mcg to 15
mcg, 1.5 mcg to 50 mcg, 1.5 mcg to 25 mcg, 1.5 mcg to 20 mcg, 1.5
mcg to 15 mcg, 2 mcg to 50 mcg, 2 mcg to 25 mcg, 2 mcg to 20 mcg, 2
mcg to 15 mcg, 2.5 mcg to 30 mcg, 2.5 mcg to 25 mcg, 2.5 mcg to 20
mcg, 2.5 mcg to 15 mcg, 3 mcg to 25 mcg, 3 mcg to 20 mcg, or 3 mcg
to 15 mcg, typically within a pharmaceutically acceptable carrier.
Moreover, any of the foregoing amounts may also serve as a dosage,
which may be administered, for example, once or twice per day, or
by any other suitable regime as discussed above.
[0046] In some embodiments, the pharmaceutical composition include
bryostatin (e.g., bryostatin-1) in an amount of 5 mcg to 20 mcg, 5
mcg to 10 mcg, 4 mcg to 6 mcg, 6 mcg to 8 mcg, 8 mcg to 10 mcg, 10
mcg to 12 mcg, 12 mcg to 14 mcg, 14 mcg to 16 mcg, 16 mcg to 18
mcg, or 18 mcg to 20 mcg. In some embodiments, the pharmaceutical
compositions used in the methods include bryostatin (e.g.,
bryostatin-1) in an amount of 0.1 mcg, 0.25 mcg, 0.5 mcg, 1 mcg,
2.5 mcg, 3 mcg, 4 mcg, 5 mcg, 7 mcg, 7.5 mcg, 10 mcg, 12.5 mcg, 15
mcg, 17.5 mcg, or 20 mcg. Moreover, any of the foregoing amounts
may also serve as a dosage, which may be administered, for example,
once or twice per day, or by any other suitable regime as discussed
above.
[0047] The pharmaceutical compositions used in the methods of the
present disclosure may be administered by any suitable regimen,
such as a regimen of 1 to 4 times per day. In some embodiments, the
compositions are administered twice a week, once a week, once every
two weeks, once every three weeks, once every four weeks, once
every six weeks, once every eight weeks or less or more frequently
depending on the needs of the patient. In some embodiments, the
compositions used in the methods of the present disclosure may be
administered as part of a course of treatment lasting for about 1
to about 30 days; about 1 to about 90 days; about 1 to about 120
days; about 1 to about 180 days; about 1 to 365 days; one year; two
years; three years; or for the patient's lifetime. In some
embodiments, the compositions used in the methods of the present
disclosure may be administered as part of a course of treatment
lasting for at least about 5 weeks; at least about 9 weeks; at
least about 13 weeks; at least about 15 weeks. Nevertheless, the
specific dose level and frequency of dosage for any particular host
may be varied and will depend upon a variety of factors, including
the activity of the specific compound employed, the metabolic
stability and length of action of that compound, the age, body
weight, general health, sex, diet, mode and time of administration,
rate of excretion, drug combination, the nature of the disorder,
the severity of the particular disorder, and the host undergoing
therapy.
[0048] To facilitate a better understanding of the present
invention, the following examples of specific embodiments are
given. In no way should the following examples be read to limit or
define the entire scope of this disclosure.
EXAMPLES
Example 1
[0049] In a double-blind, randomized, placebo-controlled trial,
bryostatin was administered by intravenous infusion (.about.45
minutes) to patients with advanced Alzheimer's disease for 12 weeks
at doses of 20 or 40 .mu.g. Randomization was stratified at
baseline by severe (MMSE-2, 4-9) and moderate (MMSE-2, 10-15)
dementia, wherein MMSE-2 refers to Mini-Mental State Examination,
version 2. The MMSE or Folstein test is a 30-point questionnaire
that is used extensively in clinical and research settings to
measure cognitive impairment. Low scores indicate greater
impairment. Version 2 of the MMSE was published in 2010, expanding
the original questionnaire's usefulness in populations with milder
forms of cognitive impairment. Safety results were similar to
placebo for 20 .mu.g with more adverse events in the 40 .mu.g
group. The 20 .mu.g dosing arm, but not the 40 .mu.g dosing arm,
showed sustained efficacy with respect to baseline as well as with
respect to the Placebo group--as measured by positive changes in
the Severe Impairment Battery (SIB). Importantly, this cognitive
improvement persisted and increased 30 days after all bryostatin
dosing had been completed. This improvement did not occur in the
presence of memantine (NMDA receptor antagonist) background
therapy.
Methods
[0050] Adults aged 55-85 with cognitive deficits present for at
least 2 years, MMSE-2 of 4-15, inclusive, and a diagnosis of
Alzheimer's dementia were randomly assigned to receive blinded
intravenous infusions of bryostatin 24 .mu.g or matching placebo at
weeks 0 and 1. The 24 .mu.g and 48 .mu.g doses during the first two
weeks of the 20 and 40 .mu.g protocols respectively were considered
to be "loading" doses thought to be beneficial from prior
experience with Compassionate Use trial patients. Nelson et al.,
Alzheimers Dis. 2017 58: 521-535. In one arm, the two 24 .mu.g
doses were followed by 20 .mu.g doses at weeks 5, 7, 9 and 11 with
the Severe Impairment Battery (SIB) measured at baseline and weeks
5, 9, 13, and 15. In a second arm, the two 48 .mu.g doses at weeks
0 and 1 were followed by 40 .mu.g doses at weeks 5, 7, 9, and 11
with the SIB measured at baseline and weeks 5, 9, 13, and 15. The
subjects were stratified by MMSE-2 in two strata: Stratum 1 (4-9)
and Stratum 2 (10-15). The first primary endpoint was safety and
tolerability, assessed by treatment emergent adverse events (TEAEs)
with a sample size of 150 subjects randomized 1:1:1. Although
efficacy was the secondary measure, the primary efficacy endpoint
was SIB improvement at week 13 evaluated using a mixed model for
repeated measures. A secondary efficacy endpoint was ADCS-ADL Sev.
The primary safety population included all subjects who received at
least 1 dose of study drug, and efficacy was evaluated in a
modified intent to treat (mITT) population that received at least 1
dose of study drug and had at least one treatment evaluation.
Efficacy was evaluated both as a primary end-point in the modified
intent-to-treat (mITT) population and also as a primary end point
in a Completers population that included all patients that
completed the entire protocols as described above.
Results
[0051] Patients who received the 20 .mu.g dose, but not patients
receiving the 40 .mu.g dose, showed a sustained improvement in SIB
versus baseline as well as the placebo patients throughout the
13-week trial (FIG. 1). It is hypothesized that the lack of
efficacy of the higher, 40 .mu.g, dose was due to prolonged down
regulation of PKC that typically follows higher and/or longer
levels of PKC activation. Nelson et al., J Biol Chem.; 2009
284(50):34514-21. As specified in the Statistical Plan that was
approved by the FDA for this exploratory trial, all p-values are
1-sided except as otherwise specified, as for example for
correlation p-values (see below), post-hoc trend analyses, and
post-hoc non-Namenda SIB improvement analyses based on direct
serial regressions, which have 2-sided p-values. The results
presented include Top Line, initial results, analysis of
exploratory endpoints, and analyses of post-hoc endpoint
results.
Sensitivity Analyses
[0052] Several sensitivity analyses were conducted and validated as
described below. MMRM (mixed model for repeat measures) analyses
for Completers were largely consistent with the corresponding FAS
analyses across several key endpoints, including
change-from-baseline scores for SIB Total, ADCS-ADL SEV Total, and
NPI. MMRM analyses for MMSE-2 and CGI-I generally showed less
separation among treatment groups than was observed for the
corresponding MMRM analyses for SIB Total Score. Analysis of
Covariance (ANCOVA) and MMRM models for SIB Total Score and
ADCS-ADL Total Score were generally similar across various
sensitivity analyses. Standard errors for the Treatment Difference
across endpoints (Changes Scores for SIB Total, ADCS-ADL Total,
MMSE-2, and NPI) and Models (ANCOVA/MMRM with and without Site,
including efficacy of acetyl-cholinesterase-inhibitor (AChEI) as a
factor, and including only larger sites) were very similar compared
to the corresponding standard errors for the treatment differences
in the main models.
[0053] Several additional sensitivity analyses included a random
site term gave results which were very similar to the results for
the fixed effects model. This reinforces reliance on the primary
model, which reasonably accounts for the effect of dropouts, the
impact of sites, and baseline covariates. Using a quantitative
baseline MMSE variable resulted in a slight improvement in
sensitivity, but the results were very similar to the results using
a categorical factor for baseline MMSE stratification. A
sensitivity analysis using z-score carried forward (using two
iterations) to account for dropouts and increase power was also
conducted. The first iteration of the z-score imputation shows some
separation of the treatment groups as compared to the original
means from the MMRM model. The second iteration of the z-score
imputation showed results which were very similar to the results
from the first iteration, indicating that two iterations was
sufficient. Although there was some improvement in power, the
results were similar enough to the results from MMRM that the use
of z-score imputation was not needed. Correction for baseline NPI
Total Score was done in the primary mixed model to assess the
possible impact. Forest plots show better effects for some items,
especially for the 40 .mu.g dose. The results across endpoints were
much more consistent with each other than the results without the
correction for baseline NPI.
Significant SIB Improvement at 5 Weeks was Correlated with Weeks 9
and 13 Efficacy:
[0054] By week 5 (after 3 bryostatin doses had been administered),
patients in the 20 .mu.g arm showed a significant improvement (FIG.
1) in the SIB scores compared to the placebo patients and compared
to their baseline scores (p=0.016, Completers' Group; p=0.056;
FAS).
[0055] As shown below (Table 1), the magnitude of the change scores
in the 20 .mu.g group at 5 weeks was significantly correlated with
the change scores observed at 9 and 13 weeks (p<0.001). These
and other between-week correlations support the consistency of the
SIB improvements produced by the 20 .mu.g doses throughout the
trial. These correlations also suggest that the patients who showed
improvement at 5 weeks (p=-016) were the same patients who showed
improvement at 9 and 13 weeks. The placebo group showed similar
between visit correlations with the strongest correlations between
weeks 5, 9, and 13 (p<0.001).
[0056] The correlations between visits were generally not as strong
in the 40 .mu.g group (found to produce no SIB improvement) at any
of the visits. The correlations and p-values for the change scores
for SIB (and ADC--poor between-group) for the 20 .mu.g group are
given in Table 1 below.
TABLE-US-00001 TABLE 1 Correlations and p-values for Total SIB and
ADCS-ADL Change Scores by Visit for the Bryostatin 20 .mu.g group
Table 1: Bryostatin SIB SIB SIB ADL ADL ADL 20 .mu.g Week 5 Week 9
Week 13 Week 5 Week 9 Week 13 SIB Week 5 Correlation 1 0.54375
0.52677 0.24549 0.11371 0.05365 p-value 0.0004 0.0007 0.1126 0.5028
0.7525 SIB Week 9 Correlation 1 0.77013 0.28524 0.41538 0.34885
p-value <.0001 0.087 0.0106 0.037 SIB Week 13 Correlation 1
0.24172 0.2795 0.15441 p-value 0.1495 0.0988 0.3615 ADL Week 5
Correlation 1 0.75136 0.58849 p-value <.0001 0.0001 ADL Week 9
Correlation 1 0.70214 p-value <.0001 ADL Week 13 Correlation
1
At 30 Days Post-Dosing (Week 15), the 20 .mu.g Group Showed SIB
Improvement:
[0057] The SIB efficacy measurement at 30 days (week 15) post
dosing--after all dosing had been completed (last dose administered
at week 11)--was a pre-specified exploratory endpoint. Week 15
results were only included for subjects who were not re-randomized.
The mixed model assumes missing at random, but order of enrollment
in the trial was not random. Since order of enrollment was not
random, the assumption of missing at random is not met. For this
reason, only including week 15 for those who were not re-randomized
is an appropriate way to estimate week 15 results, but not an
appropriate way to estimate results at the earlier visits. For this
reason, estimates up through week 13 are from a mixed model that
only included data through week 13 and the week 15 estimates are
from a separate model. Results were generated using a mixed model
with repeated measures predicting change from baseline in SIB Total
Score as the response variable and using baseline score, baseline
MMSE strata, treatment, visit (categorical), and visit (treatment)
as predictors.
[0058] The 20 .mu.g patients (including week 15 for all subjects
who were not re-randomized--FAS) showed a consistent improvement at
week 15 (approximately 30 days after the last scheduled dose of
bryostatin at 11 weeks) in their SIB scores over baseline and as
compared to the Placebo patients (p=0.0503). In contrast to the
15-week SIB LS Mean improvement of 1.77, the Placebo patients
showed a decline in their LS Mean SIB scores of 1.82 (with a
treatment difference of 3.59) points from Baseline to week 15 (see
Table 2 and FIG. 2). For the Completers group, there was a
persistent improvement (30 days after the last scheduled dose of
bryostatin at 11 weeks) in their SIB scores over baseline and as
compared to the Placebo patients (p=0.0293). This corresponds to a
treatment difference of the 20 .mu.g patients from Placebo patients
at 15 weeks of 4.09 (See FIGS. 2 and 3).
TABLE-US-00002 TABLE 2 By Visit SIB Total: MMRM for Bryostatin 20
.mu.g vs. Placebo Bryostatin Bryostatin Time Placebo - 20 .mu.g -
Placebo - 20 .mu.g - Point FAS FAS Completer Completer Week 5 n 46
44 42 38 LS Mean (SE) -1.77 (1.496) 1.18 (1.102) -2.33 (1.583) 1.67
(0.964) Difference vs. Placebo 2.96 4.00 p-value 0.0563 0.0164 80%
CI for the difference 0.58, 5.34 1.63, 6.38 Week 9 n 43 38 42 37 LS
Mean (SE) -0.09 (1.469) 0.94 (1.149) -0.57 (1.539) 1.28 (1.119)
Difference vs. Placebo 1.03 1.85 p-value 0.2898 0.1650 80% CI for
the difference -1.36, 3.42 -0.59, 4.29 Week 13 n 42 38 42 38 LS
Mean (SE) -0.79 (1.328) 1.16 (1.150) -1.12 (1.387) 1.51 (1.118)
Difference vs. Placebo 1.94 2.63 p-value 0.1340 0.0699 80% CI for
the difference -0.31, 4.19 0.35, 4.91 Week 15* n 27 26 27 26 LS
Mean (SE) -1.82 (1.727) 1.77 (1.342) -2.13 (1.758) 1.96 (1.255)
Difference vs. Placebo 3.59 4.09 p-value 0.0503 0.0293 80% CI for
the difference 0.79, 6.39 1.33, 6.85 *Results from Week 15 are from
a model that included all visits.
Dose Efficacy is Supported when Efficacy is Referenced to Body
Surface Area Analysis (BSA)
[0059] Normalization of the 20 .mu.g doses to each patient's BSA
(body surface area) revealed that the 20 .mu.g doses--on a
per-patient-basis were tightly distributed around the 12.5
.mu.g/m.sup.2 (20 .mu.g) dose, whereas the 40 .mu.g doses on a
per-patient-basis were broadly distributed around 25 .mu.g/m.sup.2.
The week 13 mean dose adjusted for body surface area was 11.33
.mu.g/m.sup.2 in the 20 .mu.g dose group and was 21.34
.mu.g/m.sup.2 in the 40 .mu.g dose group. These differences in
distribution, as quantified by the F ratio (the ratio of the
variance measures for 20 .mu.g and the 40 .mu.g dose distributions)
suggest that the 20 .mu.g dose patients may have received effective
dose levels--at the frequency used in this protocol (cf. AAIC,
2017). The ratio of the variance for the 40 .mu.g group divided by
the variance for the 20 .mu.g group results in an F-ratio of 3.97
and a corresponding 2-sided p-value of <0.0001, supporting a
conclusion of unequal variances. See FIG. 8. Comprehensive BSA
results for both bryostatin dose groups by visit showed that
results for completers were similar to those from the mITT
population.
[0060] FIG. 8 shows the distribution with BSA normalization for
both bryostatin dose arms for subjects with SIB Total scores at
Week 5. The figures for each additional follow-up visit are similar
since the BSA data is unchanged. The only difference between
figures is that subjects who were missing SIB Total score at the
specified visit were not represented in the figure for that
visit.
Memantine Blocks Bryostatin SIB Improvement:
[0061] Results were generated using a mixed model with repeated
measures predicting change from baseline in SIB Total Score as the
response variable and using baseline score, baseline MMSE strata,
treatment, visit (categorical), visit*treatment, memantine
use*treatment, and memantine use*treatment*visit as predictors.
Again, results from week 15 were obtained from a separate model
that included week 15 data for subjects who were not re-randomized.
Results up through week 13 were from a model that included data up
through week 13 for all subjects. A difference in SIB efficacy was
found in patients treated with 20 .mu.g bryostatin with or without
memantine (Namenda) as background SOC therapy. The 20 .mu.g
patients (mITT) who were on memantine, a partial NMDA receptor
antagonist, showed no improvement in their SIB scores throughout
the week 13 observation period when compared to placebo patients
(20 .mu.g LS Mean change=-0.60 versus -0.46 for placebo, p=0.4752
for difference). In contrast, the 20 .mu.g without memantine showed
improvement throughout the week 13 observation period that was
greater than the SIB improvement previously reported (AAIC, 2017)
for the entire 20 .mu.g group (see Table 3 and FIG. 4 below). The
13-week LS Mean change in the 20 .mu.g group without memantine was
3.83 points compared to the placebo group LS Mean change of -1.29,
with a difference of 5.11 and a p-value of 0.0437. For the
Completers patient group, the 13-week LS Mean change in the 20
.mu.g group without memantine showed no improvement in their SIB
scores throughout the 13 week observation period when compared to
placebo patients (20 .mu.g LS Mean change=0.56 for placebo,
p=0.3988 for difference). In contrast, without memantine, the
13-week LS Mean change in the 20 .mu.g (Completers) was 4.22
compared to the Placebo group LS Mean change of -1.32 with a
difference of 5.53 and a p-value of 0.0338.
[0062] The 15-week LS Mean change in the 20 .mu.g group (mITT)
without memantine was 5.88 points compared to the placebo group LS
Mean change of -0.05, with a difference of 5.93 and a p-value of
0.0576. This comparison in the completer population had a
difference of 6.36 and a p-value of 0.0488. Results for the
completer population, therefore, were generally similar to the FAS
population.
TABLE-US-00003 TABLE 3 By Visit SIB Total: MMRM with Covariate
Interactions Including Memantine Use FAS Completer Without
Memantine With Memantine Without Memantine With Memantine
Bryostatin Bryostatin Bryostatin Bryostatin Time Point Placebo 20
.mu.g Placebo 20 .mu.g Placebo 20 .mu.g Placebo 20 .mu.g Overall 14
17 32 27 13 16 29 22 Patient (30.4%) (38.6%) (69.6%) (61.4%)
(31.0%) (42.1%) (69.0%) (57.9%) Counts, n (%) Week 5 LS Mean -1.74
2.74 -1.70 0.26 -2.16 3.22 -2.33 0.61 (SE) (2.760) (1.786) (1.807)
(1.392) (2.898) (1.454) (1.925) (1.224) Difference 4.48 1.96 5.38
2.94 vs. Placebo p-value 0.0857 0.1973 0.0487 0.1016 80% CI 0.29,
-1.00, 1.24, -0.02, for the 8.67 4.91 9.51 5.91 difference Week 9
LS Mean 0.87 2.95 -0.42 -0.33 0.69 3.34 -1.06 -0.16 (SE) (2.714)
(1.804) (1.773) (1.444) (2.810) (1.695) (1.866) (1.410) Difference
2.08 0.09 2.66 0.90 vs. Placebo p-value 0.2597 0.4847 0.2071 0.3522
80% CI -2.08, -2.87, -1.53, -2.14, for the 6.23 3.05 6.84 3.93
difference Week 13 LS Mean -1.29 3.83 -0.46 -0.60 -1.32 4.22 -0.96
-0.39 (SE) (2.449) (1.733) (1.608) (1.425) (2.546) (1.639) (1.688)
(1.384) Difference 5.11 -0.14 5.53 0.56 vs. Placebo p-value 0.0437
0.4752 0.0338 0.3988 80% CI 1.30, -2.92, 1.68, -2.27, for the 8.93
2.65 9.38 3.40 difference Week 15* LS Mean -0.05 5.88 -1.61 -0.83
-0.12 6.24 -2.16 -0.71 (SE) (3.151) (2.036) (2.304) (1.703) (3.225)
(2.046) (2.367) (1.728) Difference 5.93 0.79 6.36 1.45 vs. Placebo
p-value 0.0576 0.3927 0.0488 0.3120 80% CI 1.12, -2.93, 1.47,
-2.36, for the 10.73 4.50 11.25 5.25 difference
[0063] As described above, overall, the 15-week LS Mean change for
the 20 .mu.g group was 1.77 points, compared to the placebo group
LS Mean change of -1.82 points with a difference of 3.59
(p=0.0503). Memantine partially blocks the NMDA glutamate
post-synaptic receptor that is well-known to be regulated by PKC
phosphorylation. This regulation may explain prevention of
bryostatin's therapeutic efficacy for the patients on maintenance
doses of Memantine throughout this trial.
Efficacy of Secondary Psychometric, ADCS-ADL
[0064] As for the SIB, the ADCS-ADL efficacy was significant for
the 20 .mu.g but not the 40 .mu.g dose (FIG. 6). For the 20 .mu.g
dose, the mITT group showed a difference from placebo of 1.4
(p<0.104), while for the completers group (20 .mu.g) showed a
difference from placebo of 1.6 (p<0.082). Subgroups with and
without memantine (Namenda)--as background SOC therapy--were not
significantly different above placebo.
[0065] There was no evidence of treatment by efficacy of
acetyl-cholinesterase-inhibitor (AChEI) use interaction. For SIB
Total, the two sided p-value for the interaction between treatment
and AChEI use was 0.8244 and the two sided p-value for the
interaction between treatment, AChEI use and time was 0.9223.
Similar results were seen when investigating the effect of AChEI
use on treatment effect for ADCS-ADL with p-values of 0.5137 and
0.6256 (two sided), respectively. At week 13, the LS Mean
difference between 20 .mu.g group and placebo in SIB Total for
AChEI non-users was 2.00 and users was 2.09, and in ADCS-ADL for
AChEI non-users was -0.67 and users was 1.99.
Sustained SIB Benefit Reinforced by Combined Analyses
[0066] (A) MMRM-A combined treatment effect across Weeks 5, 9, and
13 was calculated as a summary of the overall treatment effect. The
estimated coefficients from the MMRM were used to compute and
average three deltas:
Combined=(.DELTA. Week 5+.DELTA. Week 9+.DELTA.Week 13)/3
[0067] The difference in the combined average treatment effects
between 20 .mu.g and placebo groups was estimated and tested for
significance using Least Square Means. For the combined analyses at
week 13, the bryostatin 20 .mu.g group in the FAS with the post-hoc
MMRM analysis showed the following:
[0068] The combined treatment effect from Weeks 5, 9, and 13 showed
a mean improvement in SIB of 2.146 (1-sided p=0.093) for bryostatin
20 .mu.g over placebo in the FAS population, and a mean improvement
of 3.089 (1-sided p=0.032) over placebo in the Completer
population.
[0069] Using the post-hoc combined analysis method, results for
both FAS and completer populations show numerically greater
improvement of bryostatin 20 .mu.g over placebo, and reached
statistical significance based on the protocol pre-specified
1-sided .alpha.=0.10 level.
[0070] By showing the summary statistic for the entire treatment
period, rather than at an arbitrary specific time point, the
results offer a more clinically relevant
interpretation--particularly the sustained nature of the SIB
improvement caused the cumulative treatment benefits of bryostatin
20 .mu.g.
[0071] An additional supplemental post-hoc analysis was conducted
using the following SAP-defined exploratory endpoint: Change from
baseline in SIB Score at the 30-day follow-up (Week 15 visit). The
post-hoc MMRM analysis was performed on the population of patients
who have a 30-Day Follow-Up Visit (N=26 for bryostatin 20 .mu.g,
and N=27 for placebo for the 17-Week Completer Set) Using the
post-hoc analysis method on the 30-Day Follow-up population of
patients yields the following:
[0072] The combined treatment effect from Weeks 5, 9, 13, and 15
shows a mean improvement in SIB of 4.721 (1-sided p=0.032) for
bryostatin 20 .mu.g over placebo. This magnitude of improvement in
SIB change is substantially larger than the improvements seen in
all previous analyses.
[0073] The estimated improvement of bryostatin 20 .mu.g over
placebo is greater at each week and for the entire treatment period
for this population, and reached statistical significance based on
the protocol pre-specified 1-sided .alpha.=0.10 level at each
visit.
[0074] These supplemental analyses of the change in baseline SIB
Score at the 30-day follow-up exploratory endpoint further suggests
that the treatment benefits of bryostatin 20 .mu.g persist after
the treatment period ends.
[0075] (B) Simple Comparisons--Post-hoc analyses of SIB scores, for
the placebo and low dose bryostatin (20 .mu.g dose) treatment arms,
stratified by exposure to memantine.
[0076] A total of 57 patients with exposure to memantine (31
placebos and 26 low dose bryostatin patients) and 33 memantine
treatment-naive patients (15 placebos and 18 low dose bryostatin
patients) were considered in the post-hoc analyses. Patients used
here are from the modified ITT FAS sample (e.g. patients with at
least one post-baseline SIB).
[0077] Unadjusted Analysis of the Primary Efficacy Endpoint: The
primary efficacy endpoint for each individual patient is the change
in average of the SIB scores obtained in the 13 to 15-week time
window from the baseline SIB score. If a patient is missing from
the study at either the 13 week or 15-week time point, then the SIB
for this time window is given as the one SIB value obtained. Since
the number of patient missing at both the 13 week and 15-week time
point was low, no SIB values were imputed. A total of 7 memantine
patients and 3 memantine naive patients in the FAS sample were
missing from the study at both week 13 and week 15.
[0078] The group difference was statistically assessed by
considering the mean primary efficacy endpoint averaged over all
patients with endpoint data in each treatment arm. The t-test for
two independent samples, assuming unequal variance, was performed
on the group difference of these means. In addition, the Wilcoxon
rank sum test was also performed to determine the robustness of the
t-test.
[0079] Tables 4 and 5 below show the treatment arm means (SD) of
the primary efficacy endpoint, and the corresponding two-sided
p-values from both the test and Wilcoxon tests. Statistical
comparisons between treatment differences in the means of the
difference in baseline SIB and SIB at times 3, 9, and 13 weeks are
given for comparison purposes.
TABLE-US-00004 TABLE 4 Simple Comparison of the Primary Efficacy
Endpoint by T-test and Wilcoxon Test for the Memantine
Treatment-Naive Patients. Placebo Low dose (20) T-test Wilcoxon
test SIB Mean SD Mean SD T P-val W P-val Delta at Week 5 -1.200
10.262 3.444 5.752 1.560 0.134 88 0.091 Delta at Week 9 0.786 7.444
3.467 7.039 0.995 0.329 76 0.203 Delta at Week 13 -1.143 6.893
4.500 7.014 2.219 0.035 66 0.058 Delta at Ave of -0.679 6.707 5.406
5.432 2.706 0.012 0.016 Week 13 and 15
TABLE-US-00005 TABLE 5 Simple Comparison of the Primary Efficacy
Endpoint by T-test and Wilcoxon Test for the Memantine Exposed
Patients. Placebo Low dose (20) T-test Wilcoxon test SIB Mean SD
Mean SD T P-val W P-val Delta at Week 5 -1.258 10.498 0.077 8.109
0.541 0.590 385 0.779 Delta at Week 9 -0.414 11.008 -0.087 6.522
0.133 0.895 328 0.919 Delta at Week 13 -0.464 10.031 -0.545 6.508
-0.035 0.973 318 0.852 Delta at Ave of -1.768 10.306 -0.727 6.388
0.438 0.664 1.000 Week 13 and 15
[0080] Adjusted Analysis of the Primary Efficacy Endpoint: Because
the post-hoc analyses presented here focuses on the subgroup of
patients defined by memantine exposure, there can be no assumption
that randomization controlled for the potential imbalance of
baseline factors between the placebo and bryostatin treatment arms
within the memantine exposure strata. Thus, any possible difference
between treatment arms within the memantine strata could be
confounded by memantine exposure. For example, it is possible that
bryostatin-treated patients in the memantine treatment-naive group
are more likely to be in the higher MMSE-2 strata versus memantine
treatment-naive placebo, which in turn might result in a higher SIB
endpoint for these patients.
[0081] Analyses of Covariance models were created to control for
potential baseline imbalances. These models compare differences in
the group means of the primary efficacy endpoints (SIB at 13/15
weeks from baseline) with the memantine strata, while controlling
for the SIB at baseline and the MMSE-2 strata at randomization.
Table 6 shows the regression results for both memantine naive and
memantine exposed groups.
TABLE-US-00006 TABLE 6 Baseline SIB and MMSE-adjusted Slopes for
Placebos and 20 .mu.g Bryostatin Patients by Memantine exposure.
Memantine Naive Memantine Exposed Baseline SIB Base SIB, MMSE-2
Baseline SIB Base SIB, MMSE-2 Treatment 5.426 (p = 0.010) 5.923 (p
= 0.002) -0.531 (p = 0.843) -0.620 (p = 0.815) (95% CI) (1.402,
9.451) (2.328, 9.518) (-5.877, 4.816) (-5.925, 4.685) Baseline SIB
-0.180 (p = 0.005) -0.243 (p < 0.001) 0.131 (p = 0.116) 0.048
(0.636) (95% CI) (-0.302, -0.058) (-0.361, -0.126) (-0.034, 0.295)
(-0.155, 0.252) MMSE-2 6.790 (p = 0.008) 4.266 (p = 0.183) (95% CI)
(1.942, 11.638) (-2.081, 10.613)
[0082] Analysis of Linear Trends in SIB over Time: In addition to
considering the difference in treatment means of the change of SIB
at each time point from the baseline, the change in SIB values over
all the time points was also considered. Initially, the slope of
each person's trajectory over all time points was estimated, from
baseline (week 0) to the week 15. The mean slopes were then
calculated for treatment arm within both memantine strata. The
means of the treatment-specific slopes were statistically compared
using the two-sample t-test and Wilcoxon rank sum test.
[0083] Table 7 shows the mean (95% CI) of the slope for each
treatment and memantine exposure combination for the unweighted
data as well as these data weighted by the number of non-zero SIB
measures.
TABLE-US-00007 TABLE 7 Mean (95% CI) Slopes, both Unweighted and
Weighted by the Number of Non-Zero SIB scores. 20 .mu.g t-test 20
.mu.g t-test Placebo Bryostatin Wilcoxon Placebo Bryostatin
Wilcoxon Unweight 0.152 0.382 P = 0.210 -0.002 -0.143 P = 0.627
Slope (-0.124, (0.130, P = 0.047 (-0.391, (-0.568, P = 0.911 0.428)
0.634) 0.387) 0.282) Weighted 0.067 0.363 P = 0.067 -0.050 -0.099 P
= 0.831 Slope (-0.166, (0.146, (-0.355, (-0.437, 0.300) 0.581)
0.254) 0.238)
Discussion:
[0084] The effects described above suggest that the 20 .mu.g dose
of bryostatin can safely produce sustained improvements in SIB
scores of moderate to severe AD patients based on SIB improvements
measured at week 13, and that these improvements may be sustained
for weeks (e.g., week 15) after the termination of the dosing
protocol (week 11). Bryostatin produces enhanced SIB improvement in
the absence of memantine, as shown in FIGS. 1-7 and Table 3 above.
Patients on memantine showed no SIB improvement at week 13 or 15
(See FIGS. 4, 5). Collectively, the overall weight and consistency
of the data provide a basis for a cognitive-improvement efficacy of
bryostatin for the advanced AD patient.
[0085] These results, of an exploratory trial of bryostatin in the
treatment of advanced Alzheimer's disease patients, are worth
considering in the context of all prior drug trials for the
treatment of advanced Alzheimer's patients.
[0086] Previous trials, ranging from neurotransmitter agonists
and/or antagonists to anti-amyloid antibodies and to gamma
secretase inhibitors, have rarely if ever produced sustained
benefit (vs. placebo) in advanced AD patients.
[0087] Here, in every analysis that was conducted, unadjusted,
adjusted with MMRM, for 13 weeks and for 15 weeks (30 days post
completion of all drug dosing) showed sustained improvement of the
SIB vs. baseline and placebo group patients. At 13 weeks for the
Completers, the delta improvement was 2.6; at 15 weeks, the
improvement delta was 4.0; and at 15 weeks--in the absence of
memantine--the delta was 6.36 (See FIG. 7). According to the
pre-specified statistical plan, all of these delta values were
significant.
[0088] In contrast to this observed improvement of SIB, most, if
not all, trials directed toward disease modification, have had a
different improvement objective: a reduction in the rate of decline
of SIB (vs. a shift of decline to improvement). None of these
trials has yet succeeded.
[0089] The sustained improvement demonstrated with bryostatin began
at 5 weeks in the Completers' group (p<0.016) that was
correlated with high statistical significance (p<0.001) with
improvement at 9, 13, and 15 weeks. These correlations suggest that
the same patients benefited throughout the 15-week trial.
[0090] It is also worth emphasizing that the memantine blocked all
benefit of bryostatin in the SIB improvement. The principle targets
of bryostatin, PKC isozymes, are known to regulate NMDA receptor
functions (blocked by memantine). Therefore, blockade of the NMDA
receptor could offset most if not all of the bryostatin-induced SIB
improvement. PKC regulation of the NMDA receptor functions includes
increasing NMDA conductance by relieving Mg++ blockade, controlling
trafficking of the NMDA receptor to the neuronal membranes, and
enhancing NMDA-induced synaptogenesis. This synaptogenesis, a
primary mechanism of action (MOA) of bryostatin demonstrated in a
variety of pre-clinical models, is mediated by bryostatin-PKC
epsilon enhancement of several synaptic growth factors that include
BDNF, NGF, and IGF.
[0091] The apparent bryostatin-induced persistence of SIB
improvement is consistent with a long-lasting consequence of PKC
epsilon-growth factor efficacy that could induce the growth and/or
maturation of synaptic networks in the brain. The present example
describes the first multiple bryostatin dose treatment of AD
patients in a double-blind, randomized, placebo-controlled phase 2
trial for 12 weeks. The results described herein surprisingly and
unexpectedly suggest that a dose level of 20 mcg can safely produce
sustained improvements in the Severe Impairment Battery (SIB)
scores of moderate to severe AD patients measured at week 13.
Moreover, these improvements may be sustained up to 4 weeks after
the termination of the dosing protocol at 11 weeks. This efficacy
was only apparent in the absence of baseline, standard of care
memantine therapy.
Example 2
[0092] The following prophetic example provides a further
assessment of the safety, tolerability and efficacy of bryostatin
in the treatment of moderately severe to severe Alzheimer's disease
subjects not receiving memantine treatment. This randomized
double-blind placebo-controlled, confirmatory study will compare
bryostatin to placebo for the treatment of moderately severe to
severe Alzheimer's disease in subjects not receiving memantine
treatment. The study may be 15 weeks in duration, including a
safety and efficacy evaluation 30 days after the last dose of study
drug. Subjects will receive 7 doses of drug during the study. The
primary efficacy endpoint will be the Severe Impairment Battery
(SIB) scale score after 12 weeks of treatment (e.g., taking an
average of SIB measures observed during the Week 13 to Week 15 time
window). Bryostatin-1 or matching Placebo will be administered
intravenous by continuous infusion over 45.+-.5 minutes.
[0093] Eligible subjects will be stratified based on Mini Mental
State Exam (MMSE-2) scores 4-9 vs. 10-15 and will be randomized 1:1
to one of two treatment arms: 20 .mu.g bryostatin or placebo for
twelve weeks. The first two doses of study drug will be a loading
dose 20% higher (i.e., 24 pig) than the assigned dose and will be
administered one week apart. Thereafter, the assigned dose of 20
.mu.g will commence with the third dose and be administered every
other week. Drug is administered IV by continuous infusion over 45
(.+-.5) minutes. Subjects are scheduled to receive seven doses over
12 weeks. Subjects who drop out prior to completing the Week 7
visit will be replaced, up to a maximum of 15 subjects. Safety and
tolerability may be determined through evaluations of adverse
events (AE), serious adverse events (SAE), physical examination
(PE), vital signs, 12-lead electrocardiogram (ECG), the Columbia
Suicide Severity Rating Scale (C-SSRS), and clinical laboratory
assessments.
[0094] Cognitive improvements will be evaluated primarily with the
Severe Impairment Battery (SIB) and secondarily with functional
improvements in the Alzheimer's Disease Cooperative
Study--Activities of Daily Living--Severe Impairment Version
(ADCL-ADL-SIV), Clinical Global Impression of Improvement (CGI-I),
and Neuropsychiatric Inventory (NPI) metrics. The primary efficacy
endpoint is defined as the SIB scale score obtained between 13 and
15 weeks post first dose. The average SIB score at 13 and 15 weeks
will be the primary efficacy end point for patients with SIB
outcome measures at both time points; otherwise, either the 13-week
or 15-week SIB will be considered as the primary efficacy endpoint
for patients present in the study at only one of these two times.
The primary efficacy analysis is based on the two-sample
t-statistics of the treatment group averages from the primary
endpoint. A Wilcoxon test will also be performed.
[0095] Patients treated with bryostatin may experience a greater
improvement in cognitive function as measured by the SIB from
baseline to the primary efficacy endpoint after 12 weeks of
treatment, as compared to patients on placebo during the same time
period. The null hypothesis will be rejected at a significance
level of a two-sided .alpha.=0.05. The test of the null hypothesis
will be a superiority test based on the two-sample t-test, and only
an improvement in the SIB score from baseline is of clinical
significance.
[0096] One of skill in the art will appreciate that the examples
herein are not intended to be limiting and that one of skill in the
art will readily be able to apply the teachings herein to treating
Alzheimer's disease. Therefore, the present methods and
compositions are well adapted to attain the ends and advantages
mentioned as well as those that are inherent therein. While
numerous changes may be made by those skilled in the art, such
changes are encompassed within the spirit of this disclosure as
illustrated, in part, by the appended claims.
* * * * *