Safety, Tolerability, and Pharmacokinetics of Crenezumab in Patients with Mild-to-Moderate Alzheimer's Disease Treated with Escalating Doses for up to 133 Weeks.

BACKGROUND: Crenezumab is a fully humanized, monoclonal anti-amyloid-ß immunoglobulin G4 antibody. OBJECTIVE: This Phase Ib study (NCT02353598) evaluated the safety, tolerability, and pharmacokinetics of crenezumabat doses of ≤120 mg/kg administered intravenously every 4 weeks (q4w). Immunogenicity and exploratory biomarkers were also evaluated. METHODS: In this multicenter, double-blind study, participants (aged 50-90 years) with mild-to-moderate Alzheimer's disease (AD) and amyloid-positive positron emission tomography (PET) scan were randomized to receive crenezumab 30 or 45 mg/kg (Cohort 1, n = 21), 60 mg/kg (Cohort 2, n = 21), or 120 mg/kg (Cohort 3, n = 19) or corresponding placebo (n = 14) intravenously q4w for 13 weeks. Seventy-one participants were subsequently enrolled in an optional open-label extension (OLE) and received crenezumab at the originally assigned dose level, except for Cohort 3 (crenezumab 60 mg/kg during OLE). Participants received regular brain MRIs to assess amyloid-related imaging abnormalities (ARIA). Results up to Week 133 are reported. RESULTS: Approximately 94% of participants experienced ≥1 adverse event (AE). Most AEs were mild or moderate; 15.5% experienced a Grade ≥3 AE. No ARIA-edema/effusion (ARIA-E) events were observed. New ARIA-micro hemorrhages and hemosiderosis (ARIA-H) were reported in 4.9% (double-blind treatment period) and 9.9% (combined double-blind treatment and OLE periods) of participants. Steady-state trough concentrations of crenezumab were dose-proportional and maintained for each dose level. CONCLUSION: Crenezumab doses of ≤120 mg/kg intravenously q4w were well tolerated. The observed safety profile for ≤133 weeks of treatment in a mild-to-moderate AD population was similar to that seen in previous trials.

Baseline demographic, clinical, and cognitive characteristics of the Alzheimer's Prevention Initiative (API) Autosomal-Dominant Alzheimer's Disease Colombia Trial.

INTRODUCTION: The API AutosomalDominant AD (ADAD) Colombia Trial is a placebo-controlled clinical trial of crenezumab in 252 cognitively unimpaired 30 to 60-year-old Presenilin 1 (PSEN1) E280A kindred members, including mutation carriers randomized to active treatment or placebo and non-carriers who receive placebo. METHODS: Of the 252 enrolled, we present data on a total of 242 mutation carriers and non-carriers matched by age range, excluding data on 10 participants to protect participant confidentiality, genetic status, and trial integrity. RESULTS: We summarize demographic, clinical, cognitive, and behavioral data from 167 mutation carriers and 75 non-carriers, 30 to 53 years of age. Carriers were significantly younger than non-carriers ((mean age ± SD) 37 ± 5 vs 42 ± 6), had significantly lower Mini Mental Status Exam (MMSE) scores (28.8 ± 1.4 vs 29.2 ± 1.0), and had consistently lower memory scores. DISCUSSION: Although PSEN1 E280A mutation carriers in the Trial are cognitively unimpaired, they have slightly lower MMSE and memory scores than non-carriers. Their demographic characteristics are representative of the local population.

Validation of a guinea pig Langendorff heart model for assessing potential cardiovascular liability of drug candidates.

INTRODUCTION: Cardiac liabilities represent a major cause of recent withdrawal of marketed drugs and also for the high attrition rate evidenced during late stage drug development. To identify molecules with potential cardiovascular risks early in drug development, a screening model of ex vivo Langendorff hearts has been validated with 26 reference compounds of various chemical and therapeutic classes. METHODS: The hearts of adult guinea pigs were maintained by retrograde perfusion in Langendorff mode, beating spontaneously at sinus rhythm or paced via the right atrium at 200 and 300 beats per minute. Multiple parameters consisting of hemodynamic function (coronary and left ventricle pressure), cardiac electrophysiology (electrocardiogram and monophasic action potential) and indices of arrhythmogenesis (triangulation, reverse-use dependence, repolarization dispersion and beat-to-beat instability), together with overt arrhythmia were evaluated simultaneously. Ascending concentrations up to either 100-fold of the determined hERG IC(50) or nominally 100 microM were routinely tested utilizing 4-6 hearts per compound. RESULTS: Each compound exhibited a unique cardiovascular profile: (i) the majority displayed concentration and heart rate-dependent mixed-ion channel or multiple-target effects that frequently resulted in bradycardia, atrioventricular block, negative inotropy, coronary vasodilatation, and QRS widening. (ii) Compounds associated with high arrhythmogenic risk in the clinic exhibited more "positive signals" at concentrations within 30-fold of their maximal therapeutic free plasma concentration than those with less arrhythmogenic potential. (iii) For several potent torsadogens, proarrhythmic indices other than the prolongation of QT/QTc and MAP duration appeared more sensitive in representing proarrhythmic liability. (iv) A scoring system was developed to assist in the rank-ordering of potential cardiotoxicants. DISCUSSION: The cardiovascular action of reference compounds profiled by this isolated heart model was generally consistent with their known mechanisms and, except for the sinus heart rate, correlated well with that observed in the clinic. Further, the overall cardiac liability estimated by the scoring system matched the clinical documentation, suggesting this model could serve as a valuable tool in early cardiovascular drug safety assessment.

A place for high-throughput electrophysiology in cardiac safety: screening hERG cell lines and novel compounds with the ion works HTTM system.

Several commercially available pharmaceutical compounds have been shown to block the IKr current of the cardiac action potential. This effect can cause a prolongation of the electrocardiogram QT interval and a delay in ventricular repolarization. The Food and Drug Administration recommends that all new potential drug candidates be assessed for IKr block to avoid a potentially lethal cardiac arrhythmia known as torsades de pointes. Direct compound interaction with the human ether-a-go-go- related gene (hERG) product, a delayed rectifier potassium channel, has been identified as a molecular mechanism of IKr block. One strategy to identify compounds with hERG liability is to monitor hERG current inhibition using electrophysiology techniques. The authors describe the Ion Works HT instrument as a tool for screening cell lines expressing hERG channels. Based on current amplitude and stability criteria, a cell line was selected and used to perform a 300-compound screen. The screen was able to identify compounds with hERG activity within projects that spanned different therapeutic areas. The cell line selection and optimization, as well as the screening abilities of the Ion Works HT system, provide a powerful means of assessing hERGactive compounds early in the drug discovery pipeline.

Automated electrophysiology in the preclinical evaluation of drugs for potential QT prolongation.

INTRODUCTION: The human ether-a-go-go-related gene (hERG) potassium channel plays a major role in the electrical conductances involved in human heart repolarization. Drugs that decrease hERG K(+) currents are at risk to produce a prolongation of the cardiac action potential, resulting in an increase of the QT interval. Drug-induced QT prolongation or acquired long QT (aLQT) can lead to a fatal arrhythmia known as Torsade de Pointes (TdP). Electrophysiological methods are the best approach to evaluate potential drug candidates for hERG current inhibition. Here we identify limitations with the PatchXpress 7000A automated electrophysiology instrument and describe hERG protocol optimizations necessary for reliable preclinical assessment. METHODS: The PatchXpress 7000A automated electrophysiology system was used to evaluate a group of drugs with known hERG activity under voltage clamp conditions. We used a recombinant cell line expressing hERG, and assessed the inhibition of hERG K(+) currents at different drug concentrations. These data were used to determine hERG IC(50) values and compare assay parameters under different recording conditions. RESULTS: We found that due to limitations with the PatchXpress 7000A instrument, repeated compound additions were critical for achieving steady state drug concentrations that generated data comparable to standard patch clamp methods, particularly when similar voltage pulse protocols were implemented. Some discrepancies were observed between the PatchXpress 7000A and standard patch clamp techniques including shifts in IC(50) values for very hydrophobic compounds. Most hERG IC(50) values were within 3-fold of standard patch clamp IC(50) values. DISCUSSION: Automation of electrophysiology technologies has greatly improved the throughput of assessing lead drug candidates for hERG liability. To maintain hERG data quality comparable to standard patch clamp techniques, the PatchXpress 7000A instrument limitations should be recognized and protocols optimized accordingly to ensure accuracy.

Examining anxiety as a predictor of homicidality: a pilot study.

Homicidality rates have been shown to be more prominent among persons diagnosed with mental disorders as compared to the general population. However, the role that anxiety plays in homicidal ideation and intent is poorly understood. This study investigated predictors of homicidal intent, thought, or plan in an adult population of psychiatric inpatients diagnosed with anxiety disorders. Results suggest that the factors most strongly associated with homicidality include male gender, substance abuse, mania, and current legal problems. Multiple regression analyses showed that only male gender predicted homicidality when other variables were taken into account.