Category Archives: Medicine in general

The best laid plans of mice and men

I sent a copy of the previous post (reprinted below) about an idea to diagnose and treat chronic fatigue syndrome to Dr. Norman Sharpless, the author of the Cell review on cellular senescence.  He thought the idea was “great”; and, even better, he ran the lab which did the test I wanted to try.  I also sent a copy to a patient group.  “Solve ME/CFS Initiative”, and they want to use the post on their website.

Sharpless noted that the problem with ideas like this is accumulating patients, something the patient group could probably provide.  So all went well until 8 days ago when Dr. Sharpless was named to be the head of the National Cancer Institute, with its 4.5 billion dollar  budget by President Trump.  Being a full prof at the University of North Carolina Medical School, he would have been the ideal individual to run the study (or find someone to do it), but he now has far bigger fish to fry.

After I wrote to congratulate him, he wrote back reiterating that the idea was good, but he said he had to sever all connections with the lab he founded due to conflict of interest considerations.  He did give me the name of someone to contact there, which is where the matter stands presently.

Since the idea is based on the correlation between the amount of fatigue after chemotherapy with the level of a white cell protein (p16^INK4a), he would have had no problem accumulating chemotherapy patients as head of NCI, but again the spectre of conflict of interest rears its ugly head.  Repeating the chemotherapy study to make sure the results are in fact real is the first order of business.

So there you have a research idea, endorsed by the new head of the NCI.  I am a retired neurologist, who no longer has a license to practice medicine (but who doesn’t need a license to think).

If you’re an academic out there, looking for something to do, write up a grant proposal.  The current treatments do help people live with chronic fatigue syndrome, but they are in no sense treatments of the underlying problem.

Here is the original post

How to (possibly) diagnose and treat chronic fatigue syndrome (myalgic encephalomyelitis)

As a neurologist I saw a lot of people who were chronically tired and fatigued, because neurologists deal with muscle weakness and diseases like myasthenia gravis which are associated with fatigue.  Once I ruled out neuromuscular disease as a cause, I had nothing to offer then (nor did medicine).  Some were undoubtedly neurotic, but there was little question in my mind that some of them had something wrong that medicine just hadn’t figured out.  Not it hasn’t been trying.

Infections of almost any sort are associated with fatigue, probably because components of the inflammatory response cause it.  Anyone who’s gone through mononucleosis knows this.    The long search for an infectious cause of chronic fatigue syndrome (CFS) has had its ups and downs — particularly downs — see https://luysii.wordpress.com/2011/03/25/evil-scientists-create-virus-causing-chronic-fatigue-syndrome-in-lab/

At worst many people with these symptoms are written off as crazy; at best, depressed  and given antidepressants.  The fact that many of those given antidepressants feel better is far from conclusive, since most patients with chronic illnesses are somewhat depressed.

Even if we didn’t have a treatment, just having a test which separated sufferers from normal people would at least be of some psychological help, by telling them that they weren’t nuts.

Two recent papers may actually have the answer. Although neither paper dealt with chronic fatigue syndrome directly, and I can find no studies in the literature linking what I’m about to describe to CFS they at least imply that there could be a diagnostic test for CFS, and a possible treatment as well.

Because I expect that many people with minimal biological background will be reading this, I’ll start by describing the basic biology of cellular senescence and death

Background:  Most cells in our bodies are destined to die long before we do. Neurons are the longest lasting (essentially as long as we do).  The lining of the intestines is renewed weekly.  No circulating blood cell lasts more than half a year.

Cells die in a variety of ways.  Some are killed (by infections, heat, toxins).  This is called necrosis. Others voluntarily commit suicide (this is called apoptosis).   Sometimes a cell under stress undergoes cellular senescence, a state in which it doesn’t die, but doesn’t reproduce either.  Such cells have a variety of biochemical characteristics — they are resistant to apoptosis, they express molecules which prevent them from proliferating and most importantly, they secrete proinflammatory molecules (this is called the Senescence Associated Secretory Phenotype — SASP).

At first the very existence of the senescent state was questioned, but exist it does.  What is it good for?  Theories abound, one being that mutation is one cause of stress, and stopping mutated cells from proliferating prevents cancer. However, senescent cells are found during fetal life; and they are almost certainly important in wound healing.  They are known to accumulate the older you get and some think they cause aging.

Many stresses induce cellular senescence.  The one of interest to us is chemotherapy for cancer, something obviously good as a cancer cell turned senescent has stopped proliferating.   If you know anyone who has undergone chemotherapy, you know that fatigue is almost invariable.

One biochemical characteristic of the senescent cell is increased levels of a protein called p16^INK4a, which helps stop cellular proliferation.  While p16^INK4a can easily be measured in tissue biopsies, tissue biopsies are inherently not easy. Fortunately it can also be measured in circulating blood cells.

The following study — Cancer Discov. vol. 7 pp. 165 – 176 ’17 looked at 89 women with breast cancer undergoing chemotherapy. They correlated the amount of fatigue experienced with the levels of p16^INK4a in a type of circulating white blood cell (T lymphocyte).  There was a 44% incidence of fatigue in the highest quartile of  p16^INK4a levels, vs. a 5% incidence of fatigue in the lowest. The cited paper didn’t mention CFS nor did the highly technical but excellent review on which much of the above is based [ Cell vol. 169 pp. 1000 -1011 ’17 ]

But it is definitely time to measure p16^INK4a levels in patients with chronic fatigue and compare them to people without it.  This may be the definitive diagnostic test, if people with CFS show higher levels of p16^INK4a.

If this turns out to be the case, then there is a logical therapy for chronic fatigue syndrome.  As mentioned above, senescent cells are resistant to apoptosis (voluntary suicide).  What stops these cells from suicide? Naturally occurring cellular suicide inhibitors (with names like BCL2, BCL-XL, BCL-W) do so .  Drugs called sensolytics already exist to target the inhibitors causing senescent cells to commit suicide.

So if excessive senescent cells are the cause of CFS, then killing them should make things better. Sensolytics do exist but there are problems; one couldn’t be used because of side effects.  Others do exist (one such is Venetoclax) and have been approved by the FDA for leukemia — but it isn’t as potent .

So there is a potentially both a diagnostic test and a treatment for CFS.

The initial experiment should be fairly easy for research to do — just corral some CSF patients and controls and run a test for p16^INK4a levels in their blood cells. Also easy on the patients as only a blood draw is involved.

This, in itself, would be great, but there is far more to think about.

If CFS patients have too many senescent cells, getting rid of them — although (hopefully) symptomatically beneficial — will not get rid of what caused the senescent cells to accumulate in the first place. In addition, getting rid of all of them at once would probably cause huge problems causing something similar to the tumor lysis syndrome – https://en.wikipedia.org/wiki/Tumor_lysis_syndrome.

But these are problems CFS patients and

How to (possibly) diagnose and treat chronic fatigue syndrome (myalgic encephalomyelitis)

As a neurologist I saw a lot of people who were chronically tired and fatigued, because neurologists deal with muscle weakness and diseases like myasthenia gravis which are associated with fatigue.  Once I ruled out neuromuscular disease as a cause, I had nothing to offer then (nor did medicine).  Some were undoubtedly neurotic, but there was little question in my mind that some of them had something wrong that medicine just hadn’t figured out.  Not it hasn’t been trying.

Infections of almost any sort are associated with fatigue, probably because components of the inflammatory response cause it.  Anyone who’s gone through mononucleosis knows this.    The long search for an infectious cause of chronic fatigue syndrome (CFS) has had its ups and downs — particularly downs — see https://luysii.wordpress.com/2011/03/25/evil-scientists-create-virus-causing-chronic-fatigue-syndrome-in-lab/

At worst many people with these symptoms are written off as crazy; at best, depressed  and given antidepressants.  The fact that many of those given antidepressants feel better is far from conclusive, since most patients with chronic illnesses are somewhat depressed.

Even if we didn’t have a treatment, just having a test which separated sufferers from normal people would at least be of some psychological help, by telling them that they weren’t nuts.

Two recent papers may actually have the answer. Although neither paper dealt with chronic fatigue syndrome directly, and I can find no studies in the literature linking what I’m about to describe to CFS they at least imply that there could be a diagnostic test for CFS, and a possible treatment as well.

Because I expect that many people with minimal biological background will be reading this, I’ll start by describing the basic biology of cellular senescence and death

Background:  Most cells in our bodies are destined to die long before we do. Neurons are the longest lasting (essentially as long as we do).  The lining of the intestines is renewed weekly.  No circulating blood cell lasts more than half a year.

Cells die in a variety of ways.  Some are killed (by infections, heat, toxins).  This is called necrosis. Others voluntarily commit suicide (this is called apoptosis).   Sometimes a cell under stress undergoes cellular senescence, a state in which it doesn’t die, but doesn’t reproduce either.  Such cells have a variety of biochemical characteristics — they are resistant to apoptosis, they express molecules which prevent them from proliferating and most importantly, they secrete proinflammatory molecules (this is called the Senescence Associated Secretory Phenotype — SASP).

At first the very existence of the senescent state was questioned, but exist it does.  What is it good for?  Theories abound, one being that mutation is one cause of stress, and stopping mutated cells from proliferating prevents cancer. However, senescent cells are found during fetal life; and they are almost certainly important in wound healing.  They are known to accumulate the older you get and some think they cause aging.

Many stresses induce cellular senescence.  The one of interest to us is chemotherapy for cancer, something obviously good as a cancer cell turned senescent has stopped proliferating.   If you know anyone who has undergone chemotherapy, you know that fatigue is almost invariable.

One biochemical characteristic of the senescent cell is increased levels of a protein called p16^INK4a, which helps stop cellular proliferation.  While p16^INK4a can easily be measured in tissue biopsies, tissue biopsies are inherently not easy. Fortunately it can also be measured in circulating blood cells.

The following study — Cancer Discov. vol. 7 pp. 165 – 176 ’17 looked at 89 women with breast cancer undergoing chemotherapy. They correlated the amount of fatigue experienced with the levels of p16^INK4a in a type of circulating white blood cell (T lymphocyte).  There was a 44% incidence of fatigue in the highest quartile of  p16^INK4a levels, vs. a 5% incidence of fatigue in the lowest. The cited paper didn’t mention CFS nor did the highly technical but excellent review on which much of the above is based [ Cell vol. 169 pp. 1000 -1011 ’17 ]

But it is definitely time to measure p16^INK4a levels in patients with chronic fatigue and compare them to people without it.  This may be the definitive diagnostic test, if people with CFS show higher levels of p16^INK4a.

If this turns out to be the case, then there is a logical therapy for chronic fatigue syndrome.  As mentioned above, senescent cells are resistant to apoptosis (voluntary suicide).  What stops these cells from suicide? Naturally occurring cellular suicide inhibitors (with names like BCL2, BCL-XL, BCL-W) do so .  Drugs called sensolytics already exist to target the inhibitors causing senescent cells to commit suicide.

So if excessive senescent cells are the cause of CFS, then killing them should make things better. Sensolytics do exist but there are problems; one couldn’t be used because of side effects.  Others do exist (one such is Venetoclax) and have been approved by the FDA for leukemia — but it isn’t as potent .

So there is a potentially both a diagnostic test and a treatment for CFS.

The initial experiment should be fairly easy for research to do — just corral some CSF patients and controls and run a test for p16^INK4a levels in their blood cells. Also easy on the patients as only a blood draw is involved.

This, in itself, would be great, but there is far more to think about. 

If CFS patients have too many senescent cells, getting rid of them — although (hopefully) symptomatically beneficial — will not get rid of what caused the senescent cells to accumulate in the first place. In addition, getting rid of all of them at once would probably cause huge problems causing something similar to the tumor lysis syndrome – https://en.wikipedia.org/wiki/Tumor_lysis_syndrome.

But these are problems CFS patients and their physicians would love to have.

What is docosahexenoic acid and why should you care?

Why should drug chemists care about docosahexenoic acid — it’s a fairly trivial organic structure as these things go – a 22 carbon straight chain carboxylic acid with 6 double bonds — https://en.wikipedia.org/wiki/Docosahexaenoic_acid. However the structure is decidedly non-random (see later)

Docosahexenoic acid turns out to be crucial for the function of the blood brain barrier (BBB), something that makes it very difficult to get drugs into the brain. Years of work have shown that the only drugs able to get through the BBB are small lipid soluble molecules of mass under 400 kiloDaltons with fewer than 9 hydrogen bonds. Certainly not a large group of drugs. The more we know about the BBB, the more likely we’ll be able to figure out something to circumvent it.

The BBB was known to exist more than 100 years ago. Ehrlich found that dyes injected into the circulation were rapidly taken up by all organs except the brain. His student E. Goldmann found that dye injected into the CSF stained the brain but not other organs.

The barrier has at least two components — (1) a very tight seal between the cells lining brain blood vessels (e.g. the endothelium) — see the end of the post — (2)very low transfer across the endothelial cell from the vessel lumen. The latter is called transcytosis and involves formation of small vesicles at the lumenal surface of the endothelium, migration across the endothelial cell with release of vesicle content on the other side.

In general there are two mechanisms of transcytosis — clathrin coated pits, and caveolae. Brain endothelium shows very low rates of transcytosis. There aren’t any coated pits (no explanation I can find) and the rate of caveolar transcytosis is very low.

Dococsahexaenoic acid is the reason for the low rate of caveolar transcytosis. Here is why.

[ Nature vol. 509 pp. 432 – 433, 503 – 506, 507 – 511 ’14 Neuron vol. 82 pp. 728 – 730 ’14 ] An orphan transporter, MFSD2a (Major Facilitator Superfamily Domain containing 2a) is selectively expressed in the BBB endothelium. It is REQUIRED for formation and maintenance of BBB integrity. Animals lacking MFSD2a show uninhibited bulk transcytosis across the endothelium. The animals show no obvious defects in the junctions between the endothelial cells. Pericytes (cells in the brain layer after the endothelium) are important in keeping the levels of MFSD2a at normal levels as animals lacking them show the same defects in the BBB as those lacking MFSD2a. Even though knockouts don’t have much of a BBB, they have normal patterning of vascular networks.

MFSD2a is the major transporter of docohexaenoic acid (DHA), an omega3 fatty acid (more later). DHA isn’t made in the brain and must be transported into it. Knockouts have reduced levels of DHA in the brain accompanied by neuronal loss in the hippocampus and cerebellum and microcephaly. Human cases due to mutation are now known (11/15). Transport of DHA and fatty acids into the brain across the BBB occurs only in the form of esters with lysophosphatidylcholines (LPCs) but not as free fatty acids in a sodium dependent manner. The phospho-zwitterionic headgroup of of LPC is essential for transport. MFSD2a ‘prefers’ long chain fatty acids (oleic, palmitic), failing to transport fatty acids with chain lengths under 14.

So MFSD2a inhibits transcytosis at the same time it promotes fatty acid transport into the brain. Major Facilitator Superfamily (MFS) proteins use the electrochemical potential of the cell to transport substrates. The best known MFSs are the glucose transporters (GLUT1 – 4).

So the blood brain barrier is due in part to the lipid transport activity of MFSD2a which gives BBB endothelium a different lipid composition (with lots of docosahexenoic acid) ) than others, inhibiting caveolar transport. Increased DHA levels are associated with membrane cholesterol depletion, as well as displacement of caveolin1 (the major protein involved in this form of transcytosis) from caveolae.

It is likely that MFSD2A acts as a lipid flippase, transporting phospholipids, including DHA containing species from the outer to the inner plasma membrane leaflet (where caveolin1 binds).

What is so hot about docosahexenoic acid — 22 carbons all in a row, a carboxyl group and 6 double bonds. We’re not talking fused ring systems, alkaloids, bizarre functional groups etc. etc.

Half the answer is that the double bonds are NOT randomly arranged. The 6 occur all in a row (but with methylene groups between them). This tells the chemist that they are not conjugated, hence the chain is probably not straight. Think how unlikely the arrangement is considering the way 6 double bonds and 9 methylenes COULD be arranged in a chain (2^15). Answer 5 ways depending on where the arrangement starts relative to the end of the chain.

The other half is that all the double bonds are cis, making it very unlikely that the 21 carbon chain can straighten out and cross the membrane. Lots of DHA means a very disordered membrane, which may be impossible to caveolin1 (and clathrin) to bind to.

So even though it’s years and years since I left organic chemistry, it permits the enjoying of the biochemical esthetics of the blood brain barrier.

The tight junctions between endothelial cells are primarily responsible for barrier function. These tight junctions are found only in the capillaries and postcapillary venules of the brain. Endothelial cells of the brain have few pinocytotic vesicles and fenestriae. [ Neuron vol. 71 p. 408 ’11 ] The brain vasculature has the thinnest endothelial cells, with the tightest junction and a higher degree of pericyte coverage coverage (‘up to’ 30%). [ Neuron vol. 78 pp. 214 – 232 ’13 ] The tight junctions are made from occludin, claudins and junctional adhesion molecules, and are closer to the lumen than the adherens junctions (which also link endothelial cells to each other) made by the cadherins (E, P and N). (ibid p. 219) TLR2/6 specific stimuli.

Progress has been slow but not for want of trying

Progress in the sense of therapy for Alzheimer’s disease and Glioblastoma multiforme is essentially nonexistent, and we could use better therapy for Parkinsonism. This doesn’t mean that researchers have given up. Far from it. Three papers all in last week’s issue of PNAS came up with new understanding and possibly new therapeutic approaches for all three.

You’ll need some serious molecular biological and cell physiological chops to get through the following.

l. Glioblastoma multiforme — they aren’t living much longer than they were when I started pracice 45 years ago (about 2 years — although of course there are exceptions).

The human ZBTB family of genes consists of 49 members coding for transcription factors. BCL6 is also known as ZBTB27 and is a master regulator of lymph node germinal responses. To execute its transcriptional activity, BCL6 requires homodimerization and formation of a complex with a variety of cofactors including BCL6 corerpressor (BCoR), nuclear receptor corepressor 1 (NCoR) and Silencing Mediator of Retinoic acid and Thyroid hormone receptor (SMRT). BCL6 inhibitors block the interaction between BCL6 and its friends, selectively killing BCL6 addicted cancer cells.

The present paper [ Proc. Natl. Acad. Sci. vol. 114 pp. 3981 – 3986 ’17 ] shows that BCL6 is required for glioblastoma cell viability. One transcriptional target of BCL6 is AXL, a tyrosine kinase. Depletion of AXL also decreases proliferation of glioblastoma cells in vitro and in vivo (in a mouse model of course).

So here are two new lines of attack on a very bad disease.

2. Alzheimer’s disease — the best we can do is slow it down, certainly not improve mental function and not keep mental function from getting worse. ErbB2 is a member of the Epidermal Growth Factor Receptor (EGFR) family. It is tightly associated with neuritic plaques in Alzheimer’s. Ras GTPase activation mediates EGF induced stimulation of gamma secretase to increase the nuclear function of the amyloid precursor protein (APP) intracellular domain (AICD). ErbB2 suppresses the autophagic destruction of AICD, physically dissociating Beclin1 vrom the VPS34/VPS15 complex independently of its kinase activity.

So the following paper [ Proc. Natl. Acad. Sci. vol. 114 pp. E3129 – E3138 ’17 ] Used a compound downregulating ErbB2 function (CL-387,785) in mouse models of Alzheimer’s (which have notoriously NOT led to useful therapy). Levels of AICD declined along with beta amyloid, and the animals appeared smarter (but how smart can a mouse be?).

3.Parkinson’s disease — here we really thought we had a cure back in 1972 when L-DOPA was first released for use in the USA. Some patients looked so good that it was impossible to tell if they had the disease. Unfortunately, the basic problem (death of dopaminergic neurons) continued despite L-DOPA pills supplying what they no longer could.

Nurr1 is a protein which causes the development of dopamine neurons in the embryo. Expression of Nurr1 continues throughout life. Nurr1 appears to be a constitutively active nuclear hormone receptor. Why? Because the place where ligands (such as thyroid hormone, steroid hormones) bind to the protein is closed. A few mutations in the Nurr1 gene have been associated with familial parkinsonism.

Nurr1 functions by forming a heterodimer with the Retinoid X Receptor alpha (RXRalpha), another nuclear hormone receptor, but one which does have an open binding pocket. A compound called BRF110 was shown by the following paper [ Proc. Natl. Acad. Sci. vol. 114 pp. 3795 – 3797, 3999 – 4004 ’17 ] to bind to the ligand pocked of RXRalpha increasing its activity. The net effect is to enhance expression of dopamine neuron specific genes.

More to the point MPP+ is a toxin pretty selective for dopamine neurons (it kills them). BRF110 helps survival against MPP+ (but only if given before toxin administration). This wouldn’t be so bad because something is causing dopamine neurons to die (perhaps its a toxin), so BRF110 may fight the decline in dopamine neuron numbers, rather than treating the symptoms of dopamine deficiency.

So there you have it 3 possible new approaches to therapy for 3 bad disease all in one weeks issue of PNAS. Not easy reading, perhaps, but this is where therapy is going to come from (hopefully soon).

An obvious idea we’ve all missed

In 3+ decades as a clinical neurologist I saw several hundred unfortunate people with primary brain tumors. Not one of them was made of proliferating neurons. Not a single one. Most were tumors derived from glial cells (gliomas, glioblastomas, astrocytomas, oligodendrogliomas) which make up half the cells in the brain. Some came from the coverings of the brain (meningiomas), or the ventricular lining (ependymomas).

A recent paper in Nature (vol. 543 pp.681 – 686 ’17) decided that it might be worthwhile to figure out why some organs rarely if ever develop cancer (brain, heart, skeletal muscle). Obvious isn’t it? But no one did it until now.

Most of these tissues are terminally differentiated (unlike, skin, lung, breast and gut) and don’t undergo cellular division. This means that they don’t have to copy their DNA over and over to replenish old and dying cells, and so they are much less likely to develop mutation.

They also use oxidative phosphorylation (a mitochondrial function) rather than glycolysis to generate energy. So they looked for genes that were upregulated in terminally differentiated muscle (not brain) cells relative to proliferating muscle cell precursors. Not a complicated idea to test once you think of it (but you and I didn’t). They found 5 such, and tested them for their ability to suppress tumor growth. One such (LACTB) decreased the growth rate of a variety of tumor cells in vitro and in vivo (e.g.– when transplanted into immunodeficient animals). Amazingly it seems to have no effect on normal cells.

Showing how little we understand the goings on inside our cells, why don’t you try to guess what LACTB given your (and our) knowledge of cellular biochemistry and physiology.

LACTB changes mitochondrial lipid metabolism, by reducing the rate of decarboxylation of mitochondrial phosphatidyl serine — say what?

Even when you know what LACTB is doing you’d be hard pressed to figure out how this effect slows cancer cell growth (and possibly prevents it from occuring at all).

So given our knowledge we’d have never found LACTB and having found it we still don’t know how it works.

Why antioxidants may be bad for you

Antioxidants (vitamin E, beta carotene, vitamin C etc. etc. ) were very big a while ago. They were held to prevent all sorts of bad things (heart attack, stroke). However one pretty good study done years and years ago (see the bottom) showed that they increased the risk of lung cancer in 29,000 Finnish male smokers by 18%. People still take them however.

Now we are beginning to find out the good things that oxidation does for you. One oxidation product is 8-oxo-guanine–https://en.wikipedia.org/wiki/8-Oxoguanine — and it is estimated that it occurs 100,000 time a day in every cell in our body. This isn’t very often as we have .24 x 3,200,000 = 768,000,000 guanines in our genome.

One good thing 8-oxo-guanine may do for you is turn on gene transcription [ Proc. Natl. Acad. Sci. vol. 114 pp. 2788 – 2790, 2604 – 2609 ’17 ].This occurs when the guanine occurs in an elegant DNA structure called a G-quartet (G quadruplex) — https://en.wikipedia.org/wiki/G-quadruplex. Oxidation recruits an enzyme to remove it (8-oxo-guanine glycosylase — aka OGG1 ) generating a DNA lesion — a sugar in the backbone without a nucleotide attach. This causes the binding of Apurinic/Apyrmidic Endonuclease 1 (APE1) which recruits other things to repair the DNA.

As you know DNA in our cells is compacted 100,000 fold to fit its 1 meter length into a nucleus .00001 meters in size. Compaction involves wrapping the helix around all nucleosomes and then binding the nucleosomes together.

It’s pretty hard for RNA polymerase to even get to a gene to transcribe it into mRNA, and DNA lesions cause opening up of this compaction so repair enzymes can actually get to the double helix.

One such gene is Vascular Endothelial Growth Factor (VEGF), a gene induced by low oxygen (hypoxia). The promoter of VEGF has a potential G quadruplex sequence. If the authors put 8-oxo-guanine at 5 different positions in the G quartet, transcription of the VEGF gene was increased 2 – 3 times over the next few days. Showing the importance of the DNA lesion, if OGG1 levels were decreased this didn’t happen — showing that guanine oxidation and with the subsequent formation of a DNA lesion is required for increased transcription of VEGF.

Aside from being another mechanism for gene activation under oxidative stress, 8-oxo-guanine may actually be another epigenetic DNA modification, like 5 methyl cytosine.

So this may explain the result immediately below.

[ New England J. Med. vol. 330 pp. 1029 – 1035 ’94 ] The Alpha-Tocopherol, Beta-Carotene Trial (ATBC trial) randomized double blind placebo controlled of daily supplementation with alpha-tocopherol (a form of vitamin E), beta carotene or both to see if it reduced the incidence of lung cancer was done in 29,000 Finnish male smokers ages 50 – 69 (when most of the damage had been done). They received either alpha tocopherol 50 mg/day, beta carotene 20 mg/day or both. There was a high incidence of lung cancer (876/29000) during the 5 – 8 year period of followup. Alpha tocopherol didn’t decrease the incidence of lung cancer, and there was a higher incidence among the men receiving beta carotene (by 18%). Alpha tocopherol had no benefit on mortality (although there were more deaths from hemorrhagic stroke among the men receiving the supplement). Total mortality was 8% higher among the participants on beta carotene (more deaths from lung cancer and ischemic heart disease). It is unlikely that the dose was too low, since it was much higher than the estimated intake thought to be protective in the uncontrolled dietaryt studies. The trial organizers were so baffled by the results that they even wondered whether the beta-carotene pills used in the study had become contaminated with some known carcinogen during the manufacturing process. However, tests have ruled out that possibility.

Needless to say investigators in other beta carotene clinical trials (the Women’s Health Study, the Carotene and Retinoid Efficacy Trial) are upset. [ Science vol. 264 pp. 501 – 502 ’94 ] “In our heart of hearts, we don’t believe [ beta carotene is ] toxic” says one researcher. Touching isn’t it. Such faith in a secular age, particularly where other people’s lives are at stake. I love it when ecology, natural vitamins and pseudoscience take it in the ear.

Will flickering light treat Alzheimer’s disease ?

Big pharma has spent zillions trying to rid the brain of senile plaques, to no avail. A recent paper shows that light flickering at 40 cycles/second (40 Hertz) can do it — this is not a misprint [ Nature vol. 540 pp. 207 – 208, 230 – 235 ’16 ]. As most know the main component of the senile plaque of Alzheimer’s disease is a fragment (called the aBeta peptide) of the amyloid precursor protein (APP).

The most interesting part of the paper showed that just an hour or so of light flickering at 40 Hertz temporarily reduced the amount of Abeta peptide in visual cortex of aged mice. Nothing invasive about that.

Should we try this in people? How harmful could it be? Unfortunately the visual cortex is relatively unaffected in Alzheimer’s disease — the disease starts deep inside the head in the medial temporal lobe, particularly the hippocampus — the link shows just how deep it is -https://en.wikipedia.org/wiki/Hippocampus#/media/File:MRI_Location_Hippocampus_up..png

You might be able to do this through the squamous portion of the temporal bone which is just in front of and above the ear. It’s very thin, and ultrasound probes placed here can ‘see’ blood flowing in arteries in this region. Another way to do it might be a light source placed in the mouth.

The technical aspects of the paper are fascinating and will be described later.

First, what could go wrong?

The work shows that the flickering light activates the scavenger cells of the brain (microglia) and then eat the extracellular plaques. However that may not be a good thing as microglia could attack normal cells. In particular they are important in the remodeling of the dendritic tree (notably dendritic spines) that occurs during experience and learning.

Second, why wouldn’t it work? So much has been spent on trying to remove abeta, that serious doubt exists as to whether excessive extracellular Abeta causes Alzheimer’s and even if it does, would removing it be helpful.

Now for some fascinating detail on the paper (for the cognoscenti)

They used a mouse model of Alzheimer’s disease (the 5XFAD mouse). This poor creature has 3 different mutations associated with Alzheimer’s disease in the amyloid precursor protein (APP) — these are the Swedish (K670B), Florida (I716V) and London (V717I). If that wasn’t enough there are two Alzheimer associated mutations in one of the enzymes that processes the APP into Abeta (M146L, L286V) — using the single letter amino acid code –http://www.biochem.ucl.ac.uk/bsm/dbbrowser/c32/aacode.html.hy1. Then the whole mess is put under control of a promoter particularly active in mice (the Thy1 promoter). This results in high expression of the two mutant proteins.

So the poor mice get lots of senile plaques (particularly in the hippocampus) at an early age.

The first experiment was even more complicated, as a way was found to put channelrhodopsin into a set of hippocampal interneurons (this is optogenetics and hardly simple). Exposing the channel to light causes it to open the membrane to depolarize and the neuron to fire. Then fiberoptics were used to stimulate these neurons at 40 Hertz and the effects on the plaques were noted. Clearly a lot of work and the authors (and grad students) deserve our thanks.

Light at 8 Hertz did nothing to the plaques. I couldn’t find what other stimulation frequencies were used (assuming they were tried).

It would be wonderful if something so simple could help these people.

For other ideas about Alzheimer’s using physics rather than chemistry please see — https://luysii.wordpress.com/2014/11/30/could-alzheimers-disease-be-a-problem-in-physics-rather-than-chemistry/

In a gambling mood? Take II

I increased my holdings of ONTX (Onconova) yesterday on the basis of a trial of their drug Rigosertib jsut reported. Here’s the link — https://finance.yahoo.com/news/onconova-presents-phase-2-data-120100889.html. Basically rigosertib improved survival with no increased toxicity when added to standard therapy for myelodysplastic syndrome.

Big deal you say, that’s a relatively uncommon type of cancer. True but Rigosertib attacks the great white whale of oncology – the ras oncogene. If it works here, it may work in the forms of cancer where ras is mutated (conservatively 20 – 40% of all cancer) This is why buying ONTX is a gamble — you are balancing a 90% – 99% chance that it won’t work, with a 10 – 100 fold payoff. Here’s the old post of last May

Has the great white whale of oncology finally been harpooned?

The ras oncogene is the great white whale of oncology. Mutations in 20 – 40% of cancer turn its activity on so that nothing can turn it off, resulting in cellular proliferation. People have been trying to turn mutated ras off for years with no success.

A current paper [ Cell vol. 165 pp. 643 – 655 ’16 ] describes a new and different way to attack it. Once ras is turned on (either naturally or by mutation) many other proteins must bind to it, to produce their effects — they are called RAS effectors, among which are the uneuphoniously named RAF, RalGDS and PI3K. They bind to activated ras by the cleverly named Ras Binding Domain (RBD) which has 78 amino acids.

The paper describes rigosertib, a not that complicated molecule to the chemist, which inhibits the binding (by resembling the site on ras that the RBD binds to). It is a styryl benzyl sulfone and you can see the structure here — https://en.wikipedia.org/wiki/Rigosertib.

What’s good about it? Well it is in phase III trials for a fairly uncommon form of cancer (myelodysplastic syndrome). That means it isn’t horribly toxic or it wouldn’t have made it out of phase I.

Given the mechanism described, it is possible that Rigosertib will be useful in 20 – 40% of all cancer. Can you say blockbuster drug?

Do you have a speculative bent? Buy the company testing the drug and owning the patent — Oncova Therapeutics. It’s quite cheap — trading at $.40 (yes 40 cents !). It once traded as high as $30.00 — symbol ONTX. I don’t own any (yet), but for the price of a movie with a beer and some wings afterwards you could be the proud owner of 100 shares. If Rigosertib works, the stock will certainly increase more than a hundredfold.

Enough kidding around. This is serious business. In what follows you will find some hardcore molecular biology and cellular physiology showing just what we’re up against. Some of the following is quite old, and probably out of date (like yours truly), but it does give you the broad outlines of what is involved.

The pathway from Ras to the nucleus

The components of the pathway had been found in isolation (primarily because mutations in them were associated with malignancy). Ras was discovered as an oncogene in various sarcoma viruses. Mutations in ras found in tumors left it in a ‘turned on’ state, but just how ras (and everything else) fit into the chain of binding of a growth factor (such as platelet derived growth factor, epidermal growth factor, insulin, etc. etc.) to its receptor on the cell surface to alterations in gene expression wasn’t clear. It is certain to become more complicated, because anything as important as cellular proliferation is very likely to have a wide variety of control mechanisms superimposed on it. Although all sorts of protein kinases are involved in the pathway it is important to remember that ras is NOT a protein kinase.

l. The first step is binding of a growth factor to its receptor on the cell surface. The receptor is usually a tyrosine kinase. Binding of the factor to the receptor causes ‘activation’ of the receptor. Activation usually means increasing the enzymatic activity of the receptor in the tyrosine kinase reaction (most growth factor receptors are tyrosine kinases). The increase in activity is usually brought about by dimerization of the receptor (so it phosphorylates itself on tyrosine).

2. Most activated growth factor receptors phosphorylate themselves (as well as other proteins) on tyrosine. A variety of other proteins have domains known as SH2 (for src homology 2) which bind to phosphorylated tyrosine.

3. A protein called grb2 binds via its SH2 domain to a phosphorylated tyrosine on the receptor. Grb2 binds to the polyproline domain of another protein called sos1 via its SH3 domain. At this point, the unintiated must find the proceedings pretty hokey, but the pathway is so general (and fundamental) that proteins from yeast may be substituted into the human pathway and still have it work.

4. At last we get to ras. This protein is ‘active’ when it binds GTP, and inactive when it binds GDP. Ras is a GTPase (it can hydrolyze GTP to GDP). Most mutations which make ras an oncogene decrease the GTPase activity of RAS leaving it in a permanently ‘turned on’ state. It is important for the neurologist to know that the defective gene in type I neurofibromatosis activates the GTPase activity of ras, turning ras off. Deficiencies (in ras inactivation) lead to a variety of unusual tumors familiar to neurologists.

Once RAS has hydrolyzed GTP to GDP, the GDP remains bound to RAS inactivating it. This is the function of sos1. It catalyzes the exchange of GDP for GTP on ras, thus activating ras.

5. What does activated ras do? It activates Raf-1 silly. Raf-1 is another oncogene. How does activated ras activate Raf-1 ? Ras appears to activate raf by causing raf to bind to the cell membrane (this doesn’t happen in vitro as there is no membrane). Once ras has done its job of localizing raf to the plasma membrane, it is no longer required. How membrane localization activates raf is less than crystal clear. [ Proc. Natl. Acad. Sci. vol. 93 pp. 6924 – 6928 ’96 ] There is increasing evidence that Ras may mediate its actions by stimulating multiple downstream targets of which Raf-1 is only one.

6. Raf-1 is a protein kinase. Protein kinases work by adding phosphate groups to serine, threonine or tyrosine. In general protein kinases fall into two classes those phosphorylating on serine or threonine and those phosphorylating on tyrosine. Biochemistry has a well documented series of examples of enzymes being activated (or inhibited) by phosphorylation. The best worked out is the pathway from the binding of epinephrine to its cell surface receptor to glycogen breakdown. There is a whole sequence of one enzyme phosphorylating another which then phosphorylates a third. Something similar goes on between Raf-1 and a collection of protein kinases called MAPKs (mitogen activated protein kinases). These were discovered as kinases activated when mitogens bound to their extracellular receptors.There may be a kinase lurking about which activates Raf (it isn’t Ras which has no kinase activity). Removal of phosphate from Raf (by phosphatases) inactivates it.

7. Raf-1 activates members of the MAPK family by phosphorylating them. There may be several kinases in a row phosphorylating each other. [ Science vol. 262 pp. 1065 – 1067 ’93 ] There are at least three kinase reactions at present at this point. It isn’t known if some can be sidestepped. Raf-1 activates mitogen activated protein kinase kinase (MAPK-K) by phosphorylation (it is called MEK in the ras pathway). MAPK-K activates mitogen activation protein kinase (MAPK) by phosphorylation. Thus Raf-1 is actually mitogen activated protein kinase kinase kinase (sort of like the character in Catch-22 named Junior Junior Junior). (1/06 — I think that Raf-1 is now called BRAF)

8. The final step in the pathway is activation of transcription factors (which turn genes off or on) by MAP kinases by (what else) phosphorylation. Thus the pathway from cell surface is complete.

Play the (genetic) hand you’ve been dealt but don’t spindle, fold or mutilate your cards

Back in the day, computers were programmed by inserting multiple punch cards https://en.wikipedia.org/wiki/Punched_card, each containing a machine instruction. At the bottom of the card it said “do not fold, spindle, or mutilate”. My wife used them back then when she expected to be a widow if and when I got sent to Vietnam.

So it is with you and the genetic hand of coronary artery disease risk you’ve been dealt. [ Cell vol. 167 p. 1431 ’16 ] refers to a recent New England Journal of Medicine article –2016;DOI:http://dx.doi.org/10.1056/NEJMoa1605086.

It’s a very good study, with large numbers of participants in three prospective cohorts — 7814 participants in the Atherosclerosis Risk in Communities (ARIC) study, 21,222 in the Women’s Genome Health Study (WGHS), and 22,389 in the Malmö Diet and Cancer Study (MDCS) — plus 4260 participants in the cross-sectional BioImage Study for whom genotype and covariate data were available. Adherence to a healthy lifestyle among the participants was also determined using a scoring system consisting of four factors: no current smoking, no obesity, regular physical activity, and a healthy diet (hardly complicated).

As you probably know, Genome Wide Association Studies have identified over 50 places in our genomes in which slight variations (the technical term is single nucleotide polymorphisms — SNPs ) are associated with increased risk of coronary artery disease. Since vascular disease is a generalized problem, these SNPs also increase the risk of other vascular problems, notably stroke. None of them increases the risk very much, and even together they don’t explain much of the genetic risk of vascular disease (which we know is there). However, they were all determined (at least in the 4260) and a genetic risk score was calculated. So there were people with high, low and medium degrees of risk.

In all risk groups, high, low, whatever, a simple healthy lifestyle (no smoking, not fat, some exercise, healthy diet) decreased the coronary event rate (heart attack, death) by nearly half. So how bad was high risk? Bad indeed, the event rate in the high risk group was nearly twice that of the low risk group.

Even better, healthy lifestyle decreased risk the most just where you’d want it — in the highest risk group. You can reduce your risk of being eaten by a bear by not going to Yellowstone by 99% or more but so what.

This work is to be believed, because the number of events is high enough –1230 coronary events were observed in the ARIC cohort (median follow-up, 18.8 years), 971 coronary events in the WGHS cohort (median follow-up, 20.5 years), and 2902 coronary events in the MDCS cohort (median follow-up, 19.4 years).

So as my late father said (who lived to 100) when asked what his secret was “I chose my parents very carefully”. Well, we can’t do that, but don’t spindle the cards.

Very sad

The failure of Lilly’s antibody against the aBeta protein is very sad on several levels. My year started out going to a memorial service for a college classmate, fellow doc and friend who died of Alzheimer’s disease. He had some 50 papers to his credit mostly involving clinical evaluation of drugs such as captopril. Even so it was an uplifting experience — here’s a link –https://luysii.wordpress.com/2016/01/05/an-uplifting-way-to-start-the-new-year/

There is a large body of theory that says it should have worked. Derek Lowe’s blog “In the Pipeline” has much more — and the 80 or so comments on his post will expose you to many different points of view on Abeta — here’s the link. http://blogs.sciencemag.org/pipeline/archives/2016/11/23/eli-lillys-alzheimers-antibody-does-not-work.

It’s time to ‘let 100 flowers bloom’ in Alzheimer’s research — https://en.wikipedia.org/wiki/Hundred_Flowers_Campaign. E. g. it’s time to look at some far out possibilities — we know that most will be wrong that they will be crushed, as Mao did to all the flowers. Even so it’s worth doing.

So to buck up your spirits, here’s an old post (not a link) raising the possibility that Alzheimer’s might be a problem in physics rather than chemistry. If that isn’t enough another post follows that one on Lopid (Gemfibrozil).

Could Alzheimer’s disease be a problem in physics rather than chemistry?

Two seemingly unrelated recent papers could turn our attention away from chemistry and toward physics as the basic problem in Alzheimer’s disease. God knows we could use better therapy for Alzheimer’s disease than we have now. Any new way of looking at Alzheimer’s, no matter how bizarre,should be welcome. The approaches via the aBeta peptide, and the enzymes producing it just haven’t worked, and they’ve really been tried — hard.

The first paper [ Proc. Natl. Acad. Sci. vol. 111 pp. 16124 – 16129 ’14 ] made surfaces with arbitrary degrees of roughness, using the microfabrication technology for making computer chips. We’re talking roughness that’s almost smooth — bumps ranging from 320 Angstroms to 800. Surfaces could be made quite regular (as in a diffraction grating) or irregular. Scanning electron microscopic pictures were given of the various degrees of roughness.

Then they plated cultured primitive neuronal cells (PC12 cells) on surfaces of varying degrees of roughness. The optimal roughness for PC12 to act more like neurons was an Rq of 320 Angstroms.. Interestingly, this degree of roughness is identical to that found on healthy astrocytes (assuming that culturing them or getting them out of the brain doesn’t radically change them). Hippocampal neurons in contact with astrocytes of this degree of roughness also began extending neurites. It’s important to note that the roughness was made with something neurons and astrocytes never see — silica colloids of varying sizes and shapes.

Now is when it gets interesting. The plaques of Alzheimer’s disease have surface roughness of around 800 Angstroms. Roughness of the artificial surface of this degree was toxic to hippocampal neurons (lower degrees of roughness were not). Normal brain has a roughness with a median at 340 Angstroms.

So in some way neurons and astrocytes can sense the amount of roughness in surfaces they are in contact with. How do they do this — chemically it comes down to Piezo1 ion channels, a story in themselves [ Science vol. 330 pp. 55 – 60 ’10 ] These are membrane proteins with between 24 and 36 transmembrane segments. Then they form tetramers with a huge molecular mass (1.2 megaDaltons) and 120 or more transmembrane segments. They are huge (2,100 – 4,700 amino acids). They can sense mechanical stress, and are used by endothelial cells to sense how fast blood is flowing (or not flowing) past them. Expression of these genes in mechanically insensitive cells makes them sensitive to mechanical stimuli.

The paper is somewhat ambiguous on whether expressing piezo1 is a function of neuronal health or sickness. The last paragraph appears to have it both ways.

So as we leave paper #1, we note that that neurons can sense the physical characteristics of their environment, even when it’s something as un-natural as a silica colloid. Inhibiting Piezo1 activity by a spider venom toxin (GsMTx4) destroys this ability. The right degree of roughness is healthy for neurons, the wrong degree kills them. Clearly the work should be repeated with other colloids of a different chemical composition.

The next paper [ Science vol. 342 pp. 301, 316 – 317, 373 – 377 ’13 ] Talks about the plumbing system of the brain, which is far more active than I’d ever imaged. The glymphatic system is a network of microscopic fluid filled channels. Cerebrospinal fluid (CSF) bathes the brain. It flows into the substance of the brain (the parenchyma) along arteries, and the fluid between the cellular elements (interstitial fluid) it exchanges with flows out of the brain along the draining veins.

This work was able to measure the amount of flow through the lymphatics by injected tracer into the CSF and/or the brain parenchyma. The important point about this is that during sleep these channels expand by 60%, and beta amyloid is cleared twice as quickly. Arousal of a sleeping mouse decreases the influx of tracer by 95%. So this amazing paper finally comes up with an explanation of why we spend 1/3 of our lives asleep — to flush toxins from the brain.

If you wish to read (a lot) more about this system — see an older post from when this paper first came out — https://luysii.wordpress.com/2013/10/21/is-sleep-deprivation-like-alzheimers-and-why-we-need-sleep-in-the-first-place/

So what is the implication of these two papers for Alzheimer’s disease?

First
The surface roughness of the plaques (800 Angstroms roughness) may physically hurt neurons. The plaques are much larger or Alzheimer would never have seen them with the light microscopy at his disposal.

Second
The size of the plaques themselves may gum up the brain’s plumbing system.

The tracer work should certainly be repeated with mouse models of Alzheimer’s, far removed from human pathology though they may be.

I find this extremely appealing because it gives us a new way of thinking about this terrible disorder. In addition it might explain why cognitive decline almost invariably accompanies aging, and why Alzheimer’s disease is a disorder of the elderly.

Next, assume this is true? What would be the therapy? Getting rid of the senile plaques in and of itself might be therapeutic. It is nearly impossible for me to imagine a way that this could be done without harming the surrounding brain.

Before we all get too excited it should be noted that the correlation between senile plaque burden and cognitive function is far from perfect. Some people have a lot of plaque (there are ways to detect them antemortem) and normal cognitive function. The work also leaves out the second pathologic change seen in Alzheimer’s disease, the neurofibrillary tangle which is intracellular, not extracellular. I suppose if it caused the parts of the cell containing them to swell, it too could gum up the plumbing.

As far as I can tell, putting the two papers together conceptually might even be original. Prasad Shastri, the author of the first paper, was very helpful discussing some points about his paper by Email, but had not heard of the second and is looking at it this weekend.

Also a trial of Lopid (Gemfibrozil) as something which might be beneficial is in progress — there is some interesting theory behind this. The trial has about another year to go. Here’s that post and happy hunting

Takes me right back to grad school

How many times in grad school did you or your friends come up with a good idea, only to see it appear in the literature a few months later by someone who’d been working on it for much longer. We’d console ourselves with the knowledge that at least we were thinking well and move on.

Exactly that happened to what I thought was an original idea in my last post — e.g. that Gemfibrozil (Lopid) might slow down (or even treat) Alzheimer’s disease. I considered the post the most significant one I’d ever written, and didn’t post anything else for a week or two, so anyone coming to the blog for any reason would see it first.

A commenter on the first post gave me a name to contact to try out the idea, but I’ve been unable to reach her. Derek Lowe was quite helpful in letting me link to the post, so presently the post has had over 200 hits. Today I wrote an Alzheimer’s researcher at Yale about it. He responded nearly immediately with a link to an ongoing clinical study in progress in Kentucky

On Aug 3, 2015, at 3:04 PM, Christopher van Dyck wrote:

Dear Dr. xxxxx

Thanks for your email. I agree that this is a promising mechanism.
My colleague Greg Jicha at U.Kentucky is already working on this:
https://www.nia.nih.gov/alzheimers/clinical-trials/gemfibrozil-predementia-alzheimers-disease

Our current efforts at Yale are on other mechanisms:
http://www.adcs.org/studies/Connect.aspx

We can’t all test every mechanism, but hopefully we can collectively test the important ones.

-best regards,
Christopher H. van Dyck, MD
Professor of Psychiatry, Neurology, and Neurobiology
Director, Alzheimers Disease Research Unit

Am I unhappy about losing fame and glory being the first to think of it? Not in the slightest. Alzheimer’s is a terrible disease and it’s great to see the idea being tested.

Even more interestingly, a look at the website for the study shows, that somehow they got to Gemfibrozil by a different mechanism — microRNAs rather than PPARalpha.

I plan to get in touch with Dr. Jicha to see how he found his way to Gemfibrozil. The study is only 1 year in duration, and hopefully is well enough powered to find an effect. These studies are incredibly expensive (and an excellent use of my taxes). I never been involved in anything like this, but data mining existing HMO data simply has to be cheaper. How much cheaper I don’t know.

Here’s the previous post —

Could Gemfibrozil (Lopid) be used to slow down (or even treat) Alzheimer’s disease?

Is a treatment of Alzheimer’s disease at hand with a drug in clinical use for nearly 40 years? A paper in this week’s PNAS implies that it might (vol. 112 pp. 8445 – 8450 ’15 7 July ’15). First a lot more background than I usually provide, because some family members of the afflicted read everything they can get their hands on, and few of them have medical or biochemical training. The cognoscenti can skip past this to the text marked ***

One of the two pathologic hallmarks of Alzheimer’s disease is the senile plaque (the other is the neurofibrillary tangle). The major component of the plaque is a fragment of a protein called APP (Amyloid Precursor Protein). Normally it sits in the cellular membrane of nerve cells (neurons) with part sticking outside the cell and another part sticking inside. The protein as made by the cell contains anywhere from 563 to 770 amino acids linked together in a long chain. The fragment destined to make up the senile plaque (called the Abeta peptide) is much smaller (39 to 42 amino acids) and is found in the parts of APP embedded in the membrane and sticking outside the cell.

No protein lives forever in the cell, and APP is no exception. There are a variety of ways to chop it up, so its amino acids can be used for other things. One such chopper is called ADAM10 (aka Kuzbanian). ADAM10breaks down APP in such a way that Abeta isn’t formed. The paper essentially found that Gemfibrozil (commercial name Lopid) increases the amount of ADAM10 around. If you take a mouse genetically modified so that it will get senile plaques and decrease ADAM10 you get a lot more plaques.

The authors didn’t artificially increase the amount of ADAM10 to see if the animals got fewer plaques (that’s probably their next paper).

So there you have it. Should your loved one get Gemfibrozil? It’s a very long shot and the drug has significant side effects. For just how long a shot and the chain of inferences why this is so look at the text marked @@@@

****

How does Gemfibrozil increase the amount of ADAM10 around? It binds to a protein called PPARalpha which is a type of nuclear hormone receptor. PPARalpha binds to another protein called RXR, and together they turn on the transcription of a variety of genes, most of which are related to lipid metabolism. One of the genes turned on is ADAM10, which really has never been mentioned in the context of lipid metabolism. In any event Gemfibrozil binds to PPARalpha which binds more effectively to RAR which binds more effectively to the promoter of the ADAM10 gene which makes more ADAM10 which chops of APP in such fashion that Abeta isn’t made.

How in the world the authors got to PPARalpha from ADAM10 is unknown — but I’ve written the following to the lead author just before writing this post.

Dr. Pahan;

Great paper. People have been focused on ADAM10 for years. It isn’t clear to me how you were led to PPARgamma from reading your paper. I’m not sure how many people are still on Gemfibrozil. Probably most of them have some form of vascular disease, which increases the risk of dementia of all sorts (including Alzheimer’s). Nonetheless large HMOs have prescription data which can be mined to see if the incidence of Alzheimer’s is less on Gemfibrozil than those taking other lipid lowering agents, or the population at large. One such example (involving another class of drugs) is JAMA Intern Med. 2015;175(3):401-407, where the prescriptions of 3,434 individuals 65 years or older in Group Health, an integrated health care delivery system in Seattle, Washington. I thought the conclusions were totally unwarranted, but it shows what can be done with data already out there. Did you look at other fibrates (such as Atromid)?

Update: 22 July ’15

I received the following back from the author

Dear Dr.

Wonderful suggestion. However, here, we have focused on the basic science part because the NIH supports basic science discovery. It is very difficult to compete for NIH R01 grants using data mining approach.

It is PPARα, but not PPARγ, that is involved in the regulation of ADAM10. We searched ADAM10 gene promoter and found a site where PPAR can bind. Then using knockout cells and ChIP assay, we confirmed the participation of PPARα, the protein that controls fatty acid metabolism in the liver, suggesting that plaque formation is controlled by a lipid-lowering protein. Therefore, many colleagues are sending kudos for this publication.

Thank you.

Kalipada Pahan, Ph.D.

The Floyd A. Davis, M.D., Endowed Chair of Neurology

Professor

Departments of Neurological Sciences, Biochemistry and Pharmacology

So there you have it. An idea worth pursuing according to Dr. Pahan, but one which he can’t (or won’t). So, dear reader, take it upon yourself (if you can) to mine the data on people given Gemfibrozil to see if their risk of Alzheimer’s is lower. I won’t stand in your way or compete with you as I’m a retired clinical neurologist with no academic affiliation. The data is certainly out there, just as it was for the JAMA Intern Med. 2015;175(3):401-407 study. Bon voyage.

@@@@

There are side effects, one of which is a severe muscle disease, and as a neurologist I saw someone so severely weakened by drugs of this class that they were on a respirator being too weak to breathe (they recovered). The use of Gemfibrozil rests on the assumption that the senile plaque and Abeta peptide are causative of Alzheimer’s. A huge amount of money has been spent and lost on drugs (antibodies mostly) trying to get rid of the plaques. None have helped clinically. It is possible that the plaque is the last gasp of a neuron dying of something else (e.g. a tombstone rather than a smoking gun). It is also possible that the plaque is actually a way the neuron was defending itself against what was trying to kill it (e.g. the plaque as a pile of spent bullets).