Role of Pharmacogenomics in Individualizing Treatment for Alzheimer's Disease.


Journal

CNS drugs
ISSN: 1179-1934
Titre abrégé: CNS Drugs
Pays: New Zealand
ID NLM: 9431220

Informations de publication

Date de publication:
04 2022
Historique:
accepted: 10 03 2022
pubmed: 31 3 2022
medline: 13 4 2022
entrez: 30 3 2022
Statut: ppublish

Résumé

The development of Alzheimer's disease therapeutics has been challenging, with 99% of clinical trials failing to find a significant difference between drug and placebo. While the quest continues for more effective treatments, there is emerging evidence that pharmacogenetic considerations are important factors in regard to metabolism, efficacy, and toxicity of drugs. Currently, there are five US Food and Drug Administration-approved drugs for the treatment of Alzheimer's disease; three acetylcholinesterase inhibitors, memantine, and aducanumab. Introducing a limited genetic panel consisting of APOE4, CYP2D6*10, and BChE*K would optimize acetylcholinesterase inhibitor therapy, facilitate immunotherapy risk assessment, and inform an amyloid-related imaging abnormality surveillance schedule. In view of the genetic heterogeneity of Alzheimer's disease identified in genome-wide association studies, pharmacogenetics is expected to play an increasing role in mechanism-specific treatment strategies and personalized medicine.

Identifiants

pubmed: 35352296
doi: 10.1007/s40263-022-00915-3
pii: 10.1007/s40263-022-00915-3
doi:

Substances chimiques

Apolipoprotein E4 0
Cholinesterase Inhibitors 0
Acetylcholinesterase EC 3.1.1.7

Types de publication

Journal Article Review

Langues

eng

Sous-ensembles de citation

IM

Pagination

365-376

Informations de copyright

© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.

Références

Gale SA, Acar D, Daffner KR. Dementia. Am J Med. 2018;31(10):1161–9.
doi: 10.1016/j.amjmed.2018.01.022
Seripa D, D’Onofrio G, Panza F, et al. The genetics of the human APOE polymorphism. Rejuvenation Res. 2011;14(5):491–500.
pubmed: 21958003 doi: 10.1089/rej.2011.1169 pmcid: 21958003
Xiao T, Jiao B, Zhang W, et al. Effect of the CYP2D6 and APOE polymorphisms on the efficacy of donepezil in patients with Alzheimer’s disease: a systematic review and meta-analysis. CNS Drugs. 2016;30(10):899–907.
pubmed: 27282366 doi: 10.1007/s40263-016-0356-1 pmcid: 27282366
Wightman DP, Jansen IE, Savage JE, et al. A genome-wide association study with 1,126,563 individuals identifies new risk loci for Alzheimer’s disease. Nat Genet. 2021;53(9):1276–82.
pubmed: 34493870 doi: 10.1038/s41588-021-00921-z pmcid: 34493870
Jansen IE, Savage JE, Watanabe K, et al. Genome-wide meta-analysis identifies new loci and functional pathways influencing Alzheimer’s disease risk. Nat Genet. 2019;51(3):404–13.
pubmed: 30617256 pmcid: 6836675 doi: 10.1038/s41588-018-0311-9
Banks SJ, Qiu Y, Fan CC, et al. Enriching the design of Alzheimer’s disease clinical trials: application of the polygenic hazard score and composite outcome measures. Alzheimers Dement (N Y). 2020;6(1):e12071.
Szigeti K, Ihnatovych I, Birkaya B, et al. CHRFAM7A: a human specific fusion gene, accounts for the translational gap for cholinergic strategies in Alzheimer’s disease. EBioMedicine. 2020;59:102892.
pubmed: 32818803 pmcid: 7452451 doi: 10.1016/j.ebiom.2020.102892
Doody RS, Thomas RG, Farlow M, et al. Phase 3 trials of solanezumab for mild-to-moderate Alzheimer’s disease. N Engl J Med. 2014;370(4):311–21.
pubmed: 24450890 doi: 10.1056/NEJMoa1312889 pmcid: 24450890
Zhong Y, Zheng X, Miao Y, et al. Effect of CYP2D6*10 and APOE polymorphisms on the efficacy of donepezil in patients with Alzheimer’s disease. Am J Med Sci. 2013;345(3):222–6.
pubmed: 22986607 doi: 10.1097/MAJ.0b013e318255a8f9 pmcid: 22986607
Yaowaluk T, Senanarong V, Limwongse C, et al. Influence of CYP2D6, CYP3A5, ABCB1, APOE polymorphisms and nongenetic factors on donepezil treatment in patients with Alzheimer’s disease and vascular dementia. Pharmgenomics Pers Med. 2019;12:209–24.
pubmed: 31564952 pmcid: 6732559
Ketter N, Brashear HR, Bogert J, et al. Central review of amyloid-related imaging abnormalities in two phase III clinical trials of bapineuzumab in mild-to-moderate Alzheimer’s disease patients. J Alzheimers Dis. 2017;57(2):557–73.
pubmed: 28269765 doi: 10.3233/JAD-160216 pmcid: 28269765
Barner EL, Gray SL. Donepezil use in Alzheimer disease. Ann Pharmacother. 1998;32(1):70–7.
pubmed: 9475825 doi: 10.1345/aph.17150 pmcid: 9475825
Shintani EY, Uchida KM. Donepezil: an anticholinesterase inhibitor for Alzheimer’s disease. Am J Health Syst Pharm. 1997;54(24):2805–10.
pubmed: 9428950 doi: 10.1093/ajhp/54.24.2805 pmcid: 9428950
Noetzli M, Guidi M, Ebbing K, et al. Relationship of CYP2D6, CYP3A, POR, and ABCB1 genotypes with galantamine plasma concentrations. Ther Drug Monit. 2013;35(2):270–5.
pubmed: 23503455 doi: 10.1097/FTD.0b013e318282ff02 pmcid: 23503455
Jasiecki J, Wasag B. Butyrylcholinesterase protein ends in the pathogenesis of Alzheimer’s disease: could BCHE genotyping be helpful in Alzheimer’s therapy? Biomolecules. 2019;9(10):592.
pmcid: 6843418 doi: 10.3390/biom9100592
Prestori F, Bonardi C, Mapelli L, et al. Gating of long-term potentiation by nicotinic acetylcholine receptors at the cerebellum input stage. PLoS ONE. 2013;8(5):e64828.
pubmed: 23741401 pmcid: 3669396 doi: 10.1371/journal.pone.0064828
Shen J, Wu J. Nicotinic cholinergic mechanisms in Alzheimer’s disease. Int Rev Neurobiol. 2015;124:275–92.
pubmed: 26472533 doi: 10.1016/bs.irn.2015.08.002 pmcid: 26472533
Lewis AS, van Schalkwyk GI, Bloch MH. Alpha-7 nicotinic agonists for cognitive deficits in neuropsychiatric disorders: a translational meta-analysis of rodent and human studies. Prog Neuropsychopharmacol Biol Psychiatry. 2017;75:45–53.
pubmed: 28065843 pmcid: 5446073 doi: 10.1016/j.pnpbp.2017.01.001
Aracava Y, Pereira EF, Maelicke A, et al. Memantine blocks alpha7* nicotinic acetylcholine receptors more potently than n-methyl-D-aspartate receptors in rat hippocampal neurons. J Pharmacol Exp Ther. 2005;312(3):1195–205.
pubmed: 15522999 doi: 10.1124/jpet.104.077172 pmcid: 15522999
van Dyck CH. Anti-amyloid-beta monoclonal antibodies for Alzheimer’s disease: pitfalls and promise. Biol Psychiatry. 2018;83(4):311–9.
pubmed: 28967385 doi: 10.1016/j.biopsych.2017.08.010
Brashear HR, Ketter N, Bogert J, et al. Clinical evaluation of amyloid-related imaging abnormalities in bapineuzumab phase III studies. J Alzheimers Dis. 2018;66(4):1409–24.
pubmed: 30412493 doi: 10.3233/JAD-180675 pmcid: 30412493
Miranda LF, Gomes KB, Tito PA, et al. Clinical response to donepezil in mild and moderate dementia: relationship to drug plasma concentration and CYP2D6 and APOE genetic polymorphisms. J Alzheimers Dis. 2017;55(2):539–49.
pubmed: 27716659 doi: 10.3233/JAD-160164 pmcid: 27716659
Rigaud AS, Traykov L, Latour F, et al. Presence or absence of at least one epsilon 4 allele and gender are not predictive for the response to donepezil treatment in Alzheimer’s disease. Pharmacogenetics. 2002;12(5):415–20.
pubmed: 12142731 doi: 10.1097/00008571-200207000-00009 pmcid: 12142731
De Beaumont L, Pelleieux S, Lamarre-Theroux L, et al. Butyrylcholinesterase K and apolipoprotein E-varepsilon4 reduce the age of onset of Alzheimer’s disease, accelerate cognitive decline, and modulate donepezil response in mild cognitively impaired subjects. J Alzheimers Dis. 2016;54(3):913–22.
pubmed: 27567841 doi: 10.3233/JAD-160373 pmcid: 27567841
Salloway S, Mintzer J, Cummings JL, et al. Subgroup analysis of US and non-US patients in a global study of high-dose donepezil (23 mg) in moderate and severe Alzheimer’s disease. Am J Alzheimers Dis Other Demen. 2012;27(6):421–32.
pubmed: 22930699 doi: 10.1177/1533317512454708 pmcid: 22930699
Choi SH, Kim SY, Na HR, et al. Effect of ApoE genotype on response to donepezil in patients with Alzheimer’s disease. Dement Geriatr Cogn Disord. 2008;25(5):445–50.
pubmed: 18401173 doi: 10.1159/000124752 pmcid: 18401173
Bizzarro A, Marra C, Acciarri A, et al. Apolipoprotein E epsilon4 allele differentiates the clinical response to donepezil in Alzheimer’s disease. Dement Geriatr Cogn Disord. 2005;20(4):254–61.
pubmed: 16103669 doi: 10.1159/000087371 pmcid: 16103669
Waring JF, Tang Q, Robieson WZ, et al. APOE-varepsilon4 carrier status and donepezil response in patients with Alzheimer’s disease. J Alzheimers Dis. 2015;47(1):137–48.
pubmed: 26402762 pmcid: 4923746 doi: 10.3233/JAD-142589
Bullock R, Bergman H, Touchon J, et al. Effect of age on response to rivastigmine or donepezil in patients with Alzheimer’s disease. Curr Med Res Opin. 2006;22(3):483–94.
pubmed: 16574032 doi: 10.1185/030079906X89685 pmcid: 16574032
Blesa R, Aguilar M, Casanova JP, et al. Relationship between the efficacy of rivastigmine and apolipoprotein E (epsilon4) in patients with mild to moderately severe Alzheimer disease. Alzheimer Dis Assoc Disord. 2006;20(4):248–54.
pubmed: 17132969 doi: 10.1097/01.wad.0000213880.93665.c7
Han HJ, Kim BC, Lee JY, et al. Response to rivastigmine transdermal patch or memantine plus rivastigmine patch is affected by apolipoprotein E genotype in Alzheimer patients. Dement Geriatr Cogn Disord. 2012;34(3–4):167–73.
pubmed: 23051684 doi: 10.1159/000342927
Suh GH, Jung HY, Lee CU, et al. Effect of the apolipoprotein E epsilon4 allele on the efficacy and tolerability of galantamine in the treatment of Alzheimer’s disease. Dement Geriatr Cogn Disord. 2006;21(1):33–9.
pubmed: 16254428 doi: 10.1159/000089217
Aerssens J, Raeymaekers P, Lilienfeld S, et al. APOE genotype: no influence on galantamine treatment efficacy nor on rate of decline in Alzheimer’s disease. Dement Geriatr Cogn Disord. 2001;12(2):69–77.
pubmed: 11173877 doi: 10.1159/000051238
Babic T, Mahovic Lakusic D, Sertic J, et al. ApoE genotyping and response to galanthamine in Alzheimer’s disease: a real life retrospective study. Coll Antropol. 2004;28(1):199–204.
pubmed: 15636076
MacGowan SH, Wilcock GK, Scott M. Effect of gender and apolipoprotein E genotype on response to anticholinesterase therapy in Alzheimer’s disease. Int J Geriatr Psychiatry. 1998;13(9):625–30.
pubmed: 9777427 doi: 10.1002/(SICI)1099-1166(199809)13:9<625::AID-GPS835>3.0.CO;2-2
Wroolie TE, Kenna HA, Williams KE, et al. Cognitive effects of memantine in postmenopausal women at risk of dementia: a pilot study. Acta Neurol Scand. 2009;119(3):172–9.
pubmed: 18705678 doi: 10.1111/j.1600-0404.2008.01084.x
Lu J, Wang X, Wan L, et al. Gene polymorphisms affecting the pharmacokinetics and pharmacodynamics of donepezil efficacy. Front Pharmacol. 2020;11:934.
pubmed: 32636753 pmcid: 7317019 doi: 10.3389/fphar.2020.00934
Han HJ, Kwon JC, Kim JE, et al. Effect of rivastigmine or memantine add-on therapy is affected by butyrylcholinesterase genotype in patients with probable Alzheimer’s disease. Eur Neurol. 2015;73(1–2):23–8.
pubmed: 25376930 doi: 10.1159/000366198
Braga IL, Silva PN, Furuya TK, et al. Effect of APOE and CHRNA7 genotypes on the cognitive response to cholinesterase inhibitor treatment at different stages of Alzheimer’s disease. Am J Alzheimers Dis Other Demen. 2015;30(2):39–44.
doi: 10.1177/1533317514539540
Weng PH, Chen JH, Chen TF, et al. CHRNA7 polymorphisms and response to cholinesterase inhibitors in Alzheimer’s disease. PLoS ONE. 2013;8(12):e84059.
pubmed: 24391883 pmcid: 3877150 doi: 10.1371/journal.pone.0084059
Clarelli F, Mascia E, Santangelo R, et al. CHRNA7 gene and response to cholinesterase inhibitors in an Italian cohort of Alzheimer’s disease patients. J Alzheimers Dis. 2016;52(4):1203–8.
pubmed: 27104904 doi: 10.3233/JAD-160074 pmcid: 27104904
Salloway S, Sperling R, Fox NC, et al. Two phase 3 trials of bapineuzumab in mild-to-moderate Alzheimer’s disease. N Engl J Med. 2014;370(4):322–33.
pubmed: 24450891 pmcid: 4159618 doi: 10.1056/NEJMoa1304839
Salloway SP, Sperling R, Fox NC, et al. Long-term follow up of patients with mild-to-moderate Alzheimer’s disease treated with bapineuzumab in a phase III, open-label, extension study. J Alzheimers Dis. 2018;64(3):689–707.
pubmed: 29914022 doi: 10.3233/JAD-171157 pmcid: 29914022
Vandenberghe R, Rinne JO, Boada M, et al. Bapineuzumab for mild to moderate Alzheimer’s disease in two global, randomized, phase 3 trials. Alzheimers Res Ther. 2016;8(1):18.
pubmed: 27176461 pmcid: 4866415 doi: 10.1186/s13195-016-0189-7
Ostrowitzki S, Lasser RA, Dorflinger E, et al. A phase III randomized trial of gantenerumab in prodromal Alzheimer’s disease. Alzheimers Res Ther. 2017;9(1):95.
pubmed: 29221491 pmcid: 5723032 doi: 10.1186/s13195-017-0318-y
Sevigny J, Chiao P, Bussiere T, et al. The antibody aducanumab reduces Abeta plaques in Alzheimer’s disease. Nature. 2016;537(7618):50–6.
pubmed: 27582220 doi: 10.1038/nature19323 pmcid: 27582220
Sperling R, Salloway S, Brooks DJ, et al. Amyloid-related imaging abnormalities in patients with Alzheimer’s disease treated with bapineuzumab: a retrospective analysis. Lancet Neurol. 2012;11(3):241–9.
pubmed: 22305802 pmcid: 4063417 doi: 10.1016/S1474-4422(12)70015-7
Brody M, Liu E, Di J, et al. A phase II, randomized, double-blind, placebo-controlled study of safety, pharmacokinetics, and biomarker results of subcutaneous bapineuzumab in patients with mild to moderate Alzheimer’s disease. J Alzheimers Dis. 2016;54(4):1509–19.
pubmed: 27589523 doi: 10.3233/JAD-160369 pmcid: 27589523
Cummings JL, Cohen S, van Dyck CH, et al. ABBY: a phase 2 randomized trial of crenezumab in mild to moderate Alzheimer disease. Neurology. 2018;90(21):e1889–97.
pubmed: 29695589 pmcid: 5962917 doi: 10.1212/WNL.0000000000005550
Mintun MA, Lo AC, Duggan Evans C, et al. Donanemab in early Alzheimer’s disease. N Engl J Med. 2021;384(18):1691–704.
pubmed: 33720637 pmcid: 33720637 doi: 10.1056/NEJMoa2100708
Swanson CJ, Zhang Y, Dhadda S, et al. A randomized, double-blind, phase 2b proof-of-concept clinical trial in early Alzheimer’s disease with lecanemab, an anti-Abeta protofibril antibody. Alzheimers Res Ther. 2021;13(1):80.
pubmed: 33865446 pmcid: 8053280 doi: 10.1186/s13195-021-00813-8
Turner RM, Park BK, Pirmohamed M. Parsing interindividual drug variability: an emerging role for systems pharmacology. Wiley Interdiscip Rev Syst Biol Med. 2015;7(4):221–41.
pubmed: 25950758 pmcid: 4696409 doi: 10.1002/wsbm.1302
Ashley EA. Towards precision medicine. Nat Rev Genet. 2016;17(9):507–22.
pubmed: 27528417 doi: 10.1038/nrg.2016.86 pmcid: 27528417
Roden DM, McLeod HL, Relling MV, et al. Pharmacogenomics. Lancet. 2019;394(10197):521–32.
pubmed: 31395440 pmcid: 6707519 doi: 10.1016/S0140-6736(19)31276-0
Karch CM, Goate AM. Alzheimer’s disease risk genes and mechanisms of disease pathogenesis. Biol Psychiatry. 2015;77(1):43–51.
pubmed: 24951455 doi: 10.1016/j.biopsych.2014.05.006 pmcid: 24951455
Yamazaki Y, Zhao N, Caulfield TR, et al. Apolipoprotein E and Alzheimer disease: pathobiology and targeting strategies. Nat Rev Neurol. 2019;15(9):501–18.
pubmed: 31367008 pmcid: 7055192 doi: 10.1038/s41582-019-0228-7
Belloy ME, Napolioni V, Greicius MD. A quarter century of APOE and Alzheimer’s disease: progress to date and the path forward. Neuron. 2019;101(5):820–38.
pubmed: 30844401 pmcid: 6407643 doi: 10.1016/j.neuron.2019.01.056
Lane R, Feldman HH, Meyer J, et al. Synergistic effect of apolipoprotein E epsilon4 and butyrylcholinesterase K-variant on progression from mild cognitive impairment to Alzheimer’s disease. Pharmacogenet Genomics. 2008;18(4):289–98.
pubmed: 18334913 doi: 10.1097/FPC.0b013e3282f63f29 pmcid: 18334913
Russo P, Kisialiou A, Moroni R, et al. Effect of genetic polymorphisms (SNPs) in CHRNA7 gene on response to acetylcholinesterase inhibitors (AChEI) in patients with Alzheimer’s disease. Curr Drug Targets. 2017;18(10):1179–90.
pubmed: 26424395 doi: 10.2174/1389450116666151001111826 pmcid: 26424395
Araud T, Graw S, Berger R, et al. The chimeric gene CHRFAM7A, a partial duplication of the CHRNA7 gene, is a dominant negative regulator of alpha7*nAChR function. Biochem Pharmacol. 2011;82(8):904–14.
pubmed: 21718690 pmcid: 3162115 doi: 10.1016/j.bcp.2011.06.018
Gault J, Robinson M, Berger R, et al. Genomic organization and partial duplication of the human alpha7 neuronal nicotinic acetylcholine receptor gene (CHRNA7). Genomics. 1998;52(2):173–85.
pubmed: 9782083 doi: 10.1006/geno.1998.5363
de Lucas-Cerrillo AM, Maldifassi MC, Arnalich F, et al. Function of partially duplicated human alpha77 nicotinic receptor subunit CHRFAM7A gene: potential implications for the cholinergic anti-inflammatory response. J Biol Chem. 2011;286(1):594–606.
pubmed: 21047781 doi: 10.1074/jbc.M110.180067
Ihnatovych I, Nayak TK, Ouf A, et al. iPSC model of CHRFAM7A effect on alpha7 nicotinic acetylcholine receptor function in the human context. Transl Psychiatry. 2019;9(1):59.
pubmed: 30710073 pmcid: 6358606 doi: 10.1038/s41398-019-0375-z
Sinkus ML, Graw S, Freedman R, et al. The human CHRNA7 and CHRFAM7A genes: a review of the genetics, regulation, and function. Neuropharmacology. 2015;96(Pt B):274–88.
pubmed: 25701707 pmcid: 4486515 doi: 10.1016/j.neuropharm.2015.02.006
Ma KG, Lv J, Yang WN, et al. The p38 mitogen activated protein kinase regulates beta-amyloid protein internalization through the alpha7 nicotinic acetylcholine receptor in mouse brain. Brain Res Bull. 2018;137:41–52.
pubmed: 29128415 doi: 10.1016/j.brainresbull.2017.11.006
Wang HY, Li W, Benedetti NJ, et al. Alpha 7 nicotinic acetylcholine receptors mediate beta-amyloid peptide-induced tau protein phosphorylation. J Biol Chem. 2003;278(34):31547–53.
pubmed: 12801934 doi: 10.1074/jbc.M212532200 pmcid: 12801934
Karran E, Hardy J. Antiamyloid therapy for Alzheimer’s disease: are we on the right road? N Engl J Med. 2014;370(4):377–8.
pubmed: 24450897 doi: 10.1056/NEJMe1313943 pmcid: 24450897
Ivanoiu A, Pariente J, Booth K, et al. Long-term safety and tolerability of bapineuzumab in patients with Alzheimer’s disease in two phase 3 extension studies. Alzheimers Res Ther. 2016;8(1):24.
pubmed: 27334799 pmcid: 4918115 doi: 10.1186/s13195-016-0193-y
Tolar M, Abushakra S, Hey JA, et al. Aducanumab, gantenerumab, BAN2401, and ALZ-801-the first wave of amyloid-targeting drugs for Alzheimer’s disease with potential for near term approval. Alzheimers Res Ther. 2020;12(1):95.
pubmed: 32787971 pmcid: 7424995 doi: 10.1186/s13195-020-00663-w
Pankiewicz JE, Sadowski MJ. APOE genotype and Alzheimer’s immunotherapy. Oncotarget. 2017;8(25):39941–2.
pubmed: 28537920 pmcid: 5522246 doi: 10.18632/oncotarget.17990
Barrera-Ocampo A, Lopera F. Amyloid-beta immunotherapy: the hope for Alzheimer disease? Colomb Med (Cali). 2016;47(4):203–12.
pubmed: 28293044 pmcid: 5335861 doi: 10.25100/cm.v47i4.2640
Lin YT, Seo J, Gao F, et al. APOE4 causes widespread molecular and cellular alterations associated with Alzheimer’s disease phenotypes in human iPSC-derived brain cell types. Neuron. 2018;98(6):1141-54.e7.
pubmed: 29861287 pmcid: 6023751 doi: 10.1016/j.neuron.2018.05.008
Novak P, Schmidt R, Kontsekova E, et al. FUNDAMANT: an interventional 72-week phase 1 follow-up study of AADvac1, an active immunotherapy against tau protein pathology in Alzheimer’s disease. Alzheimers Res Ther. 2018;10(1):108.
pubmed: 30355322 pmcid: 6201586 doi: 10.1186/s13195-018-0436-1

Auteurs

Natalie Argueta (N)

State University of New York at Buffalo, 875 Ellicott St., Buffalo, NY, 14203, USA.

Emily Notari (E)

State University of New York at Buffalo, 875 Ellicott St., Buffalo, NY, 14203, USA.

Kinga Szigeti (K)

State University of New York at Buffalo, 875 Ellicott St., Buffalo, NY, 14203, USA. szigeti@buffalo.edu.

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