A double-blind, placebo-controlled multicenter study of tacrine for Alzheimer's disease. The Tacrine Collaborative Study Group.

BACKGROUND: In Alzheimer's disease, there is a marked decline in the function of cholinergic neurons in the brain. However, studies of treatment with cholinesterase inhibitors have produced conflicting results. We conducted a multicenter trial to evaluate whether the cholinesterase inhibitor tacrine (1,2,3,4-tetrahydro-9-acridinamine monohydrochloride monohydrate) could improve cognition in patients with Alzheimer's disease. METHODS: Of 632 eligible patients with probable Alzheimer's disease, 215 improved while receiving tacrine during a preliminary crossover phase to determine responsiveness and the best dose. The 215 patients were randomly assigned to receive either placebo or their best dose of tacrine (10 or 20 mg four times a day) in a six-week, double-blind trial. The primary measures of efficacy were the cognitive subscale of the Alzheimer's Disease Assessment Scale and the Clinical Global Impression of Change scale; the secondary measures included the Mini-Mental State Examination and the assessment of the activities of daily living. RESULTS: At the end of the six-week trial, the patients receiving tacrine had a mean adjusted cognitive-subscale score of 30.3 (Alzheimer's Disease Assessment Scale) as compared with 32.7 in patients receiving placebo. This represents a smaller decline (by 2.4 points) in cognitive performance in the tacrine group (P < 0.001). There were no differences between the groups in their global-rating scores. The tacrine group had a significantly smaller decline in the activities of daily living. The results of the Mini-Mental State Examination favored tacrine, but the differences were small and not statistically significant (a score of 16.0 with tacrine vs. 15.3 with placebo; P = 0.08). Gastrointestinal symptoms, elevation of aminotransferase levels, and headache were the most frequent side effects; all could be reversed by reducing the dose or discontinuing treatment. CONCLUSIONS: In this short-term study in patients with Alzheimer's disease who were selected for apparent responsiveness to tacrine, treatment with tacrine resulted in a statistically significant reduction in the decline of cognitive function, although this reduction was not large enough to be detected by the study physicians' global assessments of the patients.

Pharmacological treatment of the cognitive side effects of ECT: a review.

Electroconvulsive therapy (ECT) is an extremely effective treatment for a variety of psychiatric syndromes. However, it is frequently associated with transient cognitive side effects. Recent research has shown that these effects are sensitive to a number of treatment parameters, such as electrode placement and stimulus dosage, that the clinician may manipulate. However there have been relatively few efforts to determine if these cognitive side effects may be reduced or prevented by psychopharmacological intervention. In animals electroconvulsive shock (ECS) has been used frequently to screen for compounds which may improve cognition and memory. This paper reviews basic research studies on such compounds, as well as clinical trials in the treatment of various cognitive disorders. Studies using such compounds to reduce the cognitive side effects of ECT are exhaustively reviewed. The compounds that have been examined include: opioids, vasopressin, adrenocorticotropic hormone, other neuropeptides, cholinergic agents, nootropic agents, ergoloid mesylates, calcium-channel blockers, dexamethasone, thyroid hormone, and stimulants.

TRH protection against memory retrieval deficits is independent of endocrine effects.

An electrobrainshock (EBS)-induced memory retrieval deficit was produced in normal and hypophysectomized mice. In normal mice, thyrotropin-releasing hormone (TRH) (0.1 to 30 mg/kg) protected against this EBS disruption of memory after intraperitoneal but not oral (1.0 to 100 mg/kg) administration. In hypophysectomized mice, TRH (0.3 and 3.0 mg/kg) also protected against the retrieval deficit induced by EBS. The memory protection afforded by TRH was unrelated to its ability to elevate plasma levels of triiodothyronine (T3) and thyroxine (T4), nor was TRH's memory protection mediated through an anticonvulsive mechanism. These results support the notion that TRH may play an important role in memory modulation and may have therapeutic value in certain disease states in humans.

Early human trials in the assessment of cognition activators.

The assessment of cognition enhancers in the clinic is a broad topic that can be addressed from both academic/theoretical and therapeutic/drug development perspectives. The most important first step is to decide which perspective one is employing and to clearly specify, a priori, the goal of any intended study. Since the therapeutic benefit of cognition enhancers is not apparent until after many weeks of exposure, it is virtually impossible to demonstrate efficacy in early, short-duration Phase 2 trials. It is possible, however, to gain some knowledge of the doses that effect CNS, rCBF, PET etc. in either normal volunteers or the population of interest. However, these results should not be interpreted as evidence for, or lack of, efficacy. Recently, there has been growing interest in the reversal of scopolamine- or benzodiazepine-induced memory deficits in humans. A major problem is the potential for overinterpretation of the results of such studies. From a drug development approach, it is necessary to utilize larger numbers of subjects and longer-term studies. Specification of the indication should be as precise as possible and the outcome measures should accurately reflect both the current state of the patient and the course of the disease. The absence of normative and longitudinal data on such measures is a hurdle that is only now being overcome. Such data provide a scientific basis for the determination of the types of design and sample sizes that give adequate power to thoroughly assess new cognition enhancers.

Early clinical testing of cognition enhancers: prediction of efficacy.

The major problem in predicting clinical efficacy from animal experimental results and phase I data is the lack of resemblance between the models used and the clinical condition. This problem is complicated by the diversity of the potential mechanisms of action of new compounds. A further question is whether Phase I studies should be used as predictors of clinical efficacy at all. Should they be used simply for determining pharmacologically active dose ranges and tolerance? If used as predictors should drug development stop if negative results are obtained? These questions were not resolved. It was nonetheless suggested that some human models (e.g. scopolamine-induced amnesia, hypoxia-induced performance deficits) were indeed potential predictors of clinical response and, in addition, were analogous to similar models in animals. On the other hand characterisation of quantified EEG (QEEG) profiles remained controversial.

Steady-state pharmacokinetics of tacrine in patients with Alzheimer's disease.

Neurochemical studies of Alzheimer's disease (AD) suggest deficiencies in the cholinergic system. We evaluated the steady-state pharmacokinetics of tacrine (Cognex), an oral cholinesterase inhibitor, in 12 patients with AD. Patients sequentially received nine doses of 10 mg, 20 mg, and 30 mg of tacrine every 6 hours. Blood samples were collected until 24 hours after the final dose. Plasma tacrine concentrations were measured using a validated high-performance liquid chromatographic method. Mean maximum plasma concentrations (Cmax) were 5.1 ng/ml, 20.7 ng/ml, and 33.9 ng/ml following administration of 10 mg, 20 mg, and 30 mg doses, respectively. Corresponding mean values for steady-state area under the curve (AUC) were 19.7 ng/ml, 82.9 ng/ml, and 139 ng/ml.hr. Dose-normalized Cmax and AUC values after administration of the 20 mg and 30 mg doses of tacrine were comparable to each other but were significantly greater (p less than .05) than those after the 10 mg doses. The apparent elimination half-life was approximately 3.4 hours for all dosing regimens. Dose-dependent increases in Cmax and AUC values in patients with AD were similar to those previously reported in normal volunteers. The mechanism of the nonlinearity in tacrine pharmacokinetics is unknown.

Therapeutic trials using tacrine and other cholinesterase inhibitors.

At this time, the data available on tacrine are inconclusive with respect to efficacy. Preliminary data are often overinterpreted, and it seems prudent to wait for the results of the ongoing multicenter double-blind studies before reaching a definite conclusion about efficacy.

Animal model studies of benzodiazepine-induced amnesia.

The development of a mouse passive avoidance test as a model for amnesia produced by benzodiazepines is described. The model appropriately classifies the amnesic potential of a wide range of psychoactive drugs as validated by clinical findings. Control experiments indicate that the effect is best described as anterograde amnesia resulting from a failure of consolidation. gamma-Aminobutyric acid (GABA) antagonists had almost no effect on benzodiazepine-induced amnesia, whereas the benzodiazepine-receptor antagonist Ro 15-1788 completely and specifically reversed it. This clinically confirmed finding suggests that benzodiazepine-induced amnesia is mediated through the benzodiazepine-receptor. However, in vivo inhibition of benzodiazepine binding does not correlate well with amnesia in the mouse, and some benzodiazepine-receptor agonists with potent CNS effects in other in vitro models do not produce amnesia. Additional work is needed to clarify what aspects of benzodiazepine receptor occupancy mediate amnesia.

Benzodiazepine antagonist Ro 15-1788: neurological and behavioral effects.

In neurological and behavioral studies in mice, rats, dogs and squirrel monkeys, the imidazobenzodiazepinone Ro 15-1788 acted as a potent benzodiazepine antagonist. The antagonistic activity was both preventive and curative and seen at doses at which no intrinsic effects were detected. It was highly selective in that it acted against CNS effects induced by benzodiazepines but not against those produced by other depressants, such as phenobarbitone, meprobamate, ethanol, and valproate. The onset of action was rapid even after oral administration. Depending on the animal species studied, the antagonistic effects lasted from a few hours to 1 day. The acute and subacute toxicity of Ro 15-1788 was found to be very low. Benzodiazepine-like effects were not seen.

Associative factors underlying the pigeon's key pecking in auto-shaping procedures.

Key pecking in pigeons can be engendered by associating response-independent food presentations with illumination of a key. Specific pairings of key and food are not necessary for this phenomenon. Differential positive association between key and food (defined in terms of relative densities of reinforcement), however, is necessary and sufficient to produce and maintain key pecking. Thus, the occurrence of key pecking in auto-shaping can be considered to depend on associative processes similar to classical conditioning. Consequently, auto-shaped pecking can be virtually eliminated by the addition of food presentations in the intertrial interval, thus removing the association between key and food. Initial exposure to random reinforcement, or reinforcement only in the absence of the key, results in lower rates of pecking in subsequent auto-shaping procedures.