Effects of memantine on behavioural symptoms in Alzheimer's disease patients: an analysis of the Neuropsychiatric Inventory (NPI) data of two randomised, controlled studies.

INTRODUCTION: Behavioural symptoms are common in moderate to severe Alzheimer's disease (AD). We have analysed the databases of two randomised studies with regard to the effects of memantine treatment on behavioural symptoms, measured using the 12-item version of the Neuropsychiatric Inventory (NPI). SUBJECTS: The monotherapy study (memantine only) reported by Reisberg et al. (2003) involved 252 patients with baseline MMSE total score of between 3 and 14, whereas the combination study (memantine and donepezil) reported by Tariot et al. (2004) comprised 404 patients with MMSE scores of between 5 and 14. In both studies, patients received 10 mg memantine b.i.d. or matching placebo, and lived in the community. METHODS: For both studies NPI total and individual domains scores were analysed in the ITT population. For the monotherapy study a dichotomised analysis was performed separately for patients who had behavioural symptoms at baseline and for those without pre-existing symptoms. Furthermore, a factor analysis was used to identify any behavioural clusters within the patient population. RESULTS: In both studies, the change in NPI total scores at endpoint was consistently in favour of memantine treatment, reaching statistical significance in the combination study (p = 0.002). Memantine treatment showed a significant beneficial effect in comparison to placebo treatment in the NPI agitation/aggression domain in both studies (p = 0.008; p = 0.001). The dichotomised analysis of the monotherapy study showed that there was significantly less agitation/aggression emerging in the memantine-treated group compared to placebo (p = 0.003). Factor analysis showed that hyperactivity accounted for 27% of the data variance. CONCLUSIONS: Memantine has a beneficial effect on the behavioural symptoms of patients with moderate to severe AD, with the most pronounced effect on agitation/aggression.

Specific functional effects of memantine treatment in patients with moderate to severe Alzheimer's disease.

Treatment of Alzheimer's disease (AD) that combats progressive functional deterioration can improve the patient's quality of life and reduce caregiver burden. Memantine, a moderate affinity N-methyl-D-aspartate receptor antagonist, reduces global deterioration in AD patients and provides cognitive and functional benefits relative to placebo. Two previous studies reported statistically significant benefits of memantine for overall functional ability on the Alzheimer Disease Cooperative Study Activities of Daily Living Inventory modified for severe dementia (ADCS-ADL(19)), Functional Assessment Staging, and G2 scale. The present study reports a single-item analysis of the ADL scales from the two trials and shows that patients treated with memantine demonstrated a numerical advantage over placebo on all items assessed. These results help to translate the positive effects of memantine into specific aspects of functional ability, information that is relevant to AD patients and their families as well as to researchers interested in the assessment of functional ability in AD clinical trials.

A double-blind, placebo-controlled multicentre study of memantine in mild to moderate vascular dementia (MMM500).

The aim of the reported trial was to investigate the safety and efficacy of memantine in mild to moderate vascular dementia (VaD). This was a 28-week, double-blind, parallel, randomized controlled trial of memantine 20 mg daily versus placebo which was conducted in 54 centres in the UK. Memantine is a uncompetitive, moderate affinity N-methyl-D-aspartate receptor antagonist. Patients with a diagnosis of probable VaD and Mini Mental State Examination total scores between 10 and 22 were eligible for inclusion. Primary efficacy parameters were the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-cog) and the Clinical Global Impression of Change (CGI-C). A total of 579 patients were randomized and 548 patients with at least one post-baseline efficacy assessment qualified for the intent-to-treat analysis. At endpoint, memantine was shown to improve cognition relative to placebo in VaD: the change of ADAS-cog from baseline differed by a mean of -1.75 points (95% confidence intervals -3.023 to -0.49) and a median of 2 points between the two groups, while CGI-C ratings showed no significant differences between treatment groups. A total of 77% of all memantine-treated patients experienced adverse event, versus 75% of the placebo-treated patients, dizziness being the most frequent adverse event (11% versus 8%, respectively). Memantine was well tolerated and safe.

Measuring cognition in advanced Alzheimer's disease for clinical trials.

Measurement of cognitive dysfunction and treatment response in the early stages of Alzheimer's disease (AD) has used such scales as the Mini-Mental State Examination (MMSE) and the AD Assessment Scale (ADAS). With the exception of clinical rating scales, however, there are only a few objective measures of cognition for tracking progression in advanced AD. Given renewed interest in potential therapies for advanced AD, objective measures of cognition are important for the adequate evaluation of change due to AD progression or therapy. Several cognitive measures for advanced AD are reviewed. One measure, the Severe Impairment Battery (SIB) is reviewed in detail. Preliminary analyses from a trial of memantine show significant change on the SIB in memory (p < 0.001) and visuospatial functions (p < 0.02) over six-months with a trend for language and praxis. Data from a donepezil trial also highlight the importance of accurate assessment in advanced AD.

Glutamate receptors as a target for Alzheimer's disease--are clinical results supporting the hope?

Several years after the introduction of cholinergic drugs in Alzheimer's disease therapy, other approaches for symptomatic and also disease-modifying pharmacotherapy are progressing in their development. Among these, the NMDA antagonist memantine represents the most advanced and promising agent, gifted with many years of clinical experience in Germany. This paper provides an overview of both, the novel pharmacological background and recent clinical evidence in dementia. Memantine was recently recommended for central European approval.

New approaches to clinical trials in vascular dementia: memantine in small vessel disease.

Although criteria for the diagnosis of vascular dementia (VaD) are established, the diagnostic concept is still controversial and there is no regulatory guidance for clinical drug development. Clinical trials in VaD present a number of pitfalls and challenges and, so far, no compound has received regulatory approval for this indication. The methodological issues of clinical VaD trials are discussed using the development of memantine for this indication as an example. In a pooled analysis of two placebo-controlled trials with the NMDA-antagonist memantine in VaD, the cognitive benefit by memantine treatment was more pronounced for patients with 'small vessel disease' than for those with other neuroradiological findings at baseline. In a subgroup of patients with 'large vessel disease' or macrolesions, there was less cognitive decline among the placebo patients. It may therefore be helpful to use predefined diagnostic subcategories in clinical studies in this indication. The findings further suggest that stroke or multiple infarctions may not be the primary reason for cognitive decline in VaD patients.

Neuroprotective and symptomatological action of memantine relevant for Alzheimer's disease--a unified glutamatergic hypothesis on the mechanism of action.

The involvement of glutamate mediated neurotoxicity in the pathogenesis of Alzheimer's disease is finding increasingly more acceptance in the scientific community. Central to this hypothesis is the assumption that in particular glutamate receptors of the N-methyl-D-aspartate (NMDA) type are overactivated in a tonic rather than a phasic manner. Such continuous mild activation leads under chronic conditions to neuronal damage. Moreover, one should consider that impairment of plasticity (learning) may result not only from neuronal damage per se but also from continuous activation of NMDA receptors. To investigate this possibility we tested whether overactivation of NMDA receptors using either non-toxic doses/concentrations of a direct NMDA agonist or through an indirect approach--decrease in magnesium concentration--produces deficits in plasticity. In fact NMDA both in vivo (passive avoidance test) and in vitro (LTP in CA1 region) impaired learning and synaptic plasticity. Under these conditions memantine which is an uncompetitive NMDA receptor antagonist with features of "improved magnesium" (voltage dependence, affinity) attenuated the deficit. The more direct proof that memantine can act as a surrogate for magnesium was obtained in LTP experiments under low magnesium conditions. In this case as well, impaired LTP was restored in the presence of therapeutically relevant concentrations of memantine (1 microM). In vivo, doses leading to similar brain/serum levels produce neuroprotection in animal models relevant for neurodegeneration in Alzheimer's disease such as neurotoxicity produced by inflammation in the NBM or beta-amyloid injection to the hippocampus. Hence, we postulate that if in Alzheimer's disease overactivation of NMDA receptors occurs indeed, memantine would be expected to improve both symptoms (cognition) and slow down disease progression because it takes over the physiological function of magnesium.

Pharmacologic rationale for memantine in chronic cerebral hypoperfusion, especially vascular dementia.

Memantine is a moderate-affinity, voltage-dependent, uncompetitive antagonist of N-methyl-D-aspartate (NMDA) receptors. In contrast to competitive NMDA antagonists, Memantine is well tolerated in humans and is being developed for the treatment of dementia. The pathogenesis of vascular dementia (VaD) is largely unknown, and is likely multifactorial, but it involves the impairment of blood circulation as a common denominator. There is broad evidence for the efficacy of Memantine in several animal models of ischemia. Memantine also acts on several secondary, potentially contributing factors in VaD such as neuronal depolarization, removal of magnesium block of NMDA receptors, chronic overstimulation of these receptors, and, possibly, mitochondrial dysfunction. Among others, it also has additional positive effects on long-term potentiation and cognition in standard animal models of impaired synaptic plasticity. Recently, clinical efficacy of Memantine has been shown in an etiologically mixed population of severely demented patients, including those with VaD. Given the difficulties of diagnosing VaD in clinical practice, an optimal antidementive drug should be beneficial in both Alzheimer disease and VaD. Preclinical data presented in this paper indicate that such benefits can be achieved with Memantine. In addition, phase II clinical data in dementia are summarized, and two ongoing pivotal trials in VaD are described. Suggestions for VaD guideline development are made regarding clinical instruments, and etiologies and severity stages are considered.

The GABAB receptor antagonist CGP 36,742 and the nootropic oxiracetam facilitate the formation of long-term memory.

The memory-enhancing effects of a single treatment with the GABAB antagonist CGP 36,742 (10 mg/kg) or the nootropic agent oxiracetam (100 mg/kg) given immediately after a learning experience ('post-trial') remain detectable for at least 4 months thereafter. This indicates that in all probability these substances facilitate the formation of the long-term memory trace.

Pharmacokinetics of CGP 36,742, an orally active GABAB antagonist, in humans.

A study was conducted to evaluate the pharmacokinetics of CGP 36 742 (3-aminopropyl-n-butyl-phosphinic acid), an orally active gamma-aminobutyric acid B (GABAB) antagonist, in humans. Pharmacokinetic results after a single oral (600 mg) dose included maximum observed concentration (Cmax), 27 mumol/L (95% CI 22.9, 30.8); time to Cmax (tmax), 3 hours (median); half-life (t1/2), 3.6 hours (95% CI 3.24, 3.9); renal clearance (ClR), 125 mL/min (95% CI 114, 136); and absolute bioavailability (Fabs), 0.44 (95% CI 0.33, 0.47). Administration with food decreased the oral systemic availability (Frel) by 30%. The volume of distribution (285 L/kg) was in the order of magnitude of extracellular body water. The absorbed fraction of the compound was excreted completely and unchanged via the kidney, thus renal function would be the limiting factor for excretion. The rate of absorption and amount absorbed did not differ significantly between elderly and young healthy male volunteers, both after single and multiple doses. There was no gender-related difference in pharmacokinetics in healthy elderly volunteers. CGP 36 742 showed an excellent safety profile: there were no clinically relevant changes in cardiovascular variables, body temperature, or blood chemistry. In the placebo-controlled trial, adverse experiences were rare and evenly distributed among participants receiving placebo and the study drug. In addition, a newly developed high-performance liquid chromatography (HPLC) method for measurement of CGP 36 742 concentrations in plasma and urine using fluorescence detection is described.

Determination of rat brain and plasma levels of the orally active GABAB antagonist 3-amino-propyl-n-butyl-phosphinic acid (CGP 36742) by a new GC/MS method.

An involvement of GABAergic neurons has been suggested in the process of memory consolidation based on anatomical evidence and increasing physiological and biochemical data. With the advent of orally active GABAB antagonists, such as CGP 36742, the question of their therapeutic value, for example in Alzheimer's disease, becomes relevant. Therefore, a new GC/MS method was developed to determine the concentration of CGP 36742 (3-amino-propyl-n-butyl phosphinic acid) in various intra- and extracerebral tissues after different routes of application. The compound was chemically derivatised in a two-step process (acylation of the amino group and esterification of the phosphinic acid). The limit of detection of the method was 0.01 microgram/g tissue and 0.0005 microgram/mL plasma. The time-course after i.p. treatment showed peak levels of CGP 36742 between 30 min and 1 hr after injection. After a dose of 100 mg/kg, the concentration in the brain ranged from 1 to 1.4 microgram/g or 6 to 8 microM, assuming that 1 mg tissue equals 1 microL (i.e., below the IC50 of the interaction with GABAB receptors as measured by [3-3H]-aminopropyl-phosphinic acid binding [35 microM]). These results are discussed in light of the psychopharmacological effects (improvement of cognitive performance of rats) of CGP 36742 observed at very low oral doses.

Stereological study on the rat heart in chronic alimentary thiamine deficiency--absence of myocardial changes despite starvation.

Young male Wistar rats were fed with a thiamine-free diet for 35 days. The growth of the thiamine-deficient animals was considerably suppressed, as compared to a pair-fed control group (body weights: 140.4 +/- 4.3 g v. 243.1 +/- 4.3 g). A weight-matched control group was therefore evaluated in addition. Histological and ultrastructural investigations of the hearts did not reveal any morphological abnormalities. Stereological analysis was performed on left ventricular papillary muscles. One-way analysis of variance showed significant differences of stereological parameters between the three groups which were not associated with significant linear contrasts between the thiamine-deficient group and the weight-matched control group. Thus, the changes are not to be related to direct effects of thiamine depletion on the myocardium. Conclusively, the data indicate that stereological parameters (ratios) of the myocardium depend on heart weight and body weight, respectively, and are changed during normal growth. Our stereological estimates disclosed alterations of the following parameters: numerical density of myocardial cell nuclei, length density and volume density of capillaries, surface density of outer mitochondrial membranes and surface-to-volume ratio of mitochondria, and volume density of myofibrils. Furthermore, relative heart weights decrease in normal growth. It is concluded that our experimental model of chronic alimentary thiamine deficiency was associated with a normal structure of the myocardium. All significant differences between the thiamine-deficient group and the control group are explained by body weight changes following starvation in chronic thiamine deficiency.

Orthogonal triplet probes: an efficient method for unbiased estimation of length and surface of objects with unknown orientation in space.

If the axis of anisotropy of oriented, tubular or lamellar objects is unknown, the unbiased stereological estimation of length density and surface density (Lv and Sv) requires counts on sections with isotropic uniform random (IUR) orientation. It is shown theoretically that in homogeneous, anisotropic specimens the precision of Lv and Sv estimation is considerably augmented if IUR-oriented sets of three mutually perpendicular sections (orthogonal triplet probes = ortrips) are used instead of three directionally independent IUR sections. The mechanism of variance reduction results from a negative covariance between sections within 'ortrips' and corresponds to the antithetic variate principle of Monte Carlo work. Heterogeneity decreases the efficiency of the ortrip method, but this effect can often be counteracted by systematic sampling of ortrips within specimens. Practical estimation of length and surface area of the highly anisotropic, tubular myocardial capillaries per tissue volume in the left ventricles of eight normal, adult, male perfusion-fixed Wistar rats provided estimates of excellent precision with CEs of 3.3% (Lv) and 2.1% (Sv) of the group mean. The method will hopefully allow stereologists dealing with arbitrary anisotropic structures to apply the same simple, efficient, and unbiased sampling designs that have long been used in the study of liver, lung, and kidney tissue.