GDNF and Parkinson’s disease

In 1991, Leu-Fen Lin and Frank Collins – both research scientists at a small biotech company in Boulder, Colorado – isolated a protein that was going to have an enormous impact on experimental therapeutic approaches for Parkinson’s disease over the next two decades. The company was called Synergen, and the protein they discovered was glial cell-derived neurotrophic factor, or GDNF.

GDNF

The structure of GDNF. Source: Wikipedia

A great deal has been written about GDNF and Parkinson’s disease (there are some very good books on the story of the development of GDNF as a drug), here we will provide an overview and look at what is currently happening.

So what is GDNF?

Glial cells are the support cells in the brain. From the Greek γλία and γλοία meaning “glue”, glial cells make up more than 50% percentage of the total number of cells in the brain – though this ratio can vary across different regions.

Glial_Cells

Large neurons supported by smaller glial cells. Source: Scientific Brains

Glials cells look after the ‘work horses’ – the neurons – by maintaining the environment surrounding the neurons and supplying them with supportive chemicals, called neurotrophic factors (neurotrophic = Greek: neuron – nerve; trophikós – pertaining to food/to feed). There are many types of neurotrophic factors, some having more beneficial effects on certain types of neurons and not other. GDNF is one of these neurotrophic factors. It was isolated from a cell culture of rat glial cells (hence the name: glial cell-derived neurotrophic factor), and what became clear very quickly after it’s discovery was that it dramatically revived dying dopamine neurons (the cells classically affected in Parkinson’s disease). Leu-Fen Lin and Frank Collins’s initial results were astounding and they were published in 1993. Many studies in animal models of Parkinson’s disease followed and in almost all of those studies the results were amazing (here is a good review of the early literature).

GDNF is a member of a larger family of neurotrophic factors and three other members of that family (called neurturin, persephin, and artemin – sounds like the Three Musketeers!) have also demonstrated positive effects on dying dopamine neurons. The positive/neuroprotective effect works via a series of receptors on the surface of cells. There a receptors that are specific for each of the GDNF family members discussed above:

GDNFfamily

The GDNF family. Source: Nature

And they each exert their positive affect in combination with a protein called ret proto-oncogene (RET). RET is a receptor tyrosine kinase, which is a cell-surface molecule that initiates signals inside the cell resulting in cell growth and survival. Dopamine neurons have most of these receptors and a lot of RET.

What has happened with GDNF in the clinic?

Given the results of the initial studies with GDNF (and its family members), clinical studies/trials were set up to test if similar effects would be seen in humans.

The very first clinical trial pumped GDNF into the fluid surrounding the brain, but the drug did not penetrate very deep into the brain and had limited effect. One side effect of the treatment was a hyper-sensitivity to pain (called hyperalgesia) – patients literally couldn’t tolerate the clothes touching their bodies.

This initial failure gave rise to another clinical study at the Frenchay Hospital in Bristol (UK) in which GDNF was released inside the brain, in an area called the striatum. Tiny plastic tubes were implanted in the brain allowing for the GDNF to be pumped in.

infusion1

 

GDNF was pumped into the striatum (green area). Source: Bankiewicz lab

Although the number of subjects in the study was very small (only 5 people with Parkinson’s), the results of that particular study were simply amazing.

GDNFtitle1

Title: Direct brain infusion of glial cell line-derived neurotrophic factor in Parkinson disease.
Authors: Gill SS, Patel NK, Hotton GR, O’Sullivan K, McCarter R, Bunnage M, Brooks DJ, Svendsen CN, Heywood P.
Journal: Nat Med. 2003 May;9(5):589-95.
PMID: 12669033

The researchers reported that after just one year of GDNF treatment, there was:

  • a 39% improvement in the off-medication motor ability (according to the Unified Parkinson’s Disease Rating Scale (UPDRS))
  • a 61% improvement in how subjects perceived their ability to go about daily activities.
  • a 64% reduction in medication-induced dyskinesias (and they were not observed off medication)
  • no serious clinical side effects

Importantly, the researchers conducted brain imaging studies on the subjects and a 28% increase in striatum dopamine storage after 18 months.

And that study was followed up by an outcome report two years later, which had similar results.

GDNFtitle2

 

Title: Intraputamenal infusion of glial cell line-derived neurotrophic factor in PD: a two-year outcome study.
Authors: Patel NK, Bunnage M, Plaha P, Svendsen CN, Heywood P, Gill SS.
Journal: Ann Neurol. 2005 Feb;57(2):298-302.
PMID: 15668979

And then the researchers published a case study of one patient, suggesting that the positive effects of GDNF were still having an impact 3 years after the drug had stopped being delivered:

Title: Benefits of putaminal GDNF infusion in Parkinson disease are maintained after GDNF cessation.
Authors: Patel NK, Pavese N, Javed S, Hotton GR, Brooks DJ, Gill SS.
Journal: Neurology. 2013 Sep 24;81(13):1176-8.
PMID: 23946313

 

There were two issues with this initial GDNF pump study however:

  1. The trial was open label. Both the subjects taking part and the physicians running the study knew who was getting the drug. The study was not blind.
  2. A larger double blind study did not find the same results.

The Amgen “Double-Blind” Trial

In 2003, based on the Bristol study results, the pharmaceutical company Amgen (which owned GDNF) initiated a double blind clinical trial for GDNF with 34 patients. Being double blind, both the researchers and the participants did not know who was getting GDNF or a control treatment. The procedure used to pump the GDNF into the brain was slightly different to that used in the Bristol study, and some have suggested that this may have contributed to the outcome of this study.

On 1st July 2004, Amgen announced that its clinical trial testing the efficacy of GDNF in treating advanced Parkinson’s had failed to demonstrate any clinical improvement after six months of use. Later that year (in September), Amgen halted the study completely citing two reasons:

  • Pre-clinical data from non-human primates that had been treated in the highest dosage group for six months (followed by a three-month washout period) indicated a significant loss of neurons in an area of the brain called the cerebellum (which is involved in coordinating movement)
  • They had detected “neutralizing antibodies” in two of the study participants.

The former was strange as it had never been detected in any other animal models previously reported, but the detection of antibodies was a more serious issue. Antibodies are made by cells to defend the body against foreign material. If the body begins to produce antibodies against GDNF, the immune system would clear the body of the GDNF drug, but also the body’s own natural supply of GDNF. The consequences of this are unknown, so Amgen decided to pull the plug on the trial.

What followed was a ugly chapter in the story of GDNF. Amgen refused to allow their study participants to continue to use GDNF when they requested it on compassion reasons. Lawyers then got involved (two lawsuits in 2005), but the judges decided in favour of Amgen.

There are many researchers around the world who still believe that GDNF represents an important treatment for Parkinson’s disease, and this has given rise to further clinical trials.

What is happening at the moment?

Currently there are several GDNF-based clinical trials being conducted. These trials have focused on three methods of delivery into the brain (specifically the striatum, which is the area of the brain where the most dopamine is released):

  1. Gene Therapy (GT)
  2. Encapsulated genetically modified cells (ECB)
  3. Pump delivery

GDNF-trial

A section of human brain demonstrating the different methods

for the delivery of GDNF to the striatum. Source: EPFL

The gene therapy (GT) trials have used genetically modified viruses to deliver the GDNF family members. One of the main GT trials involved a virus that was modified so that it produced large amounts of neurturin. Subjects were injected in the brain (specifically the striatum) and then the study participants were followed for 15 months. Unfortunately, this study failed to demonstrate any meaningful improvement in subjects with Parkinson’s disease.

The Encapsulated genetically modified cells (ECB) approach for the delivery of GDNF has been developed by company called NSgene and the trial currently on-going and we are waiting to hear the results of this study.

And finally, a new pump clinical trial for GDNF trial being run in Bristol (UK). The trial is being run by a company called MedGenesis (and funded by ParkinsonsUK and the CurePDTrust). The research team in Bristol have recruited 36 people with Parkinson’s disease to take part in their 9-month trial.

_70387399_70387394

Dr Stephen Gill – Professor in Neurosurgery at University of Bristol – who conducting the current GDNF-pump study

This new trial should definitively tell us if there is a future for GDNF in Parkinson’s disease.  The results of the study are expected at the end of 2016.

Reasons why GDNF may not work

While we do not want to dampen any optimism regarding GDNF, we believe that it is important to supply all points of view and as much information as possible. That said, in 2012, researchers in Sweden discovered that the GDNF neuroprotective effect is blocked in cells over-expressing alpha-synuclein – the protein that clumps together in Parkinson’s disease. In agreement with this, they found that RET was also reduced in dopamine neurons in people with Parkinson’s disease. Thus, it may be that people with Parkinson’s disease have a reduced ability to respond to GDNF.

Decressac1

Title: α-Synuclein-induced down-regulation of Nurr1 disrupts GDNF signaling in nigral dopamine neurons.
Authors: Decressac M, Kadkhodaei B, Mattsson B, Laguna A, Perlmann T, Björklund A.
Journal: Sci Transl Med. 2012 Dec 5;4(163):163ra156.
PMID: 23220632

Luckily, the Swedish researchers also found that another protein, called Nurr1, could rescue this reduction in GDNF response. And there is now a lot of research being conducted to investigate the positive effects of GDNF and Nurr1 in combination.

We will continue to follow this area and report any new findings as they come to hand.

 

A call to arms

While our primary goal here at the Science of Parkinson’s is to highlight and explain new research dealing with Parkinson’s disease, we are also keen to encourage the general public to get involved with efforts to cure this debilitating condition.

To this end, we would like to bring your attention to the fact that 2017 represents the 200th anniversary of the first report of Parkinson’s disease by one Dr James Parkinson:

320px-Parkinson,_An_Essay_on_the_Shaking_Palsy_(first_page)

Although there were several earlier descriptions of individuals suffering from rigidity and a resting tremor, Dr Parkinson’s 66 page publication of six cases of ‘Shaking Palsy’, is considered the seminal report that gave rise to what we now call Parkinson’s disease. The report was published in 1817.

The 200th anniversary represents a fantastic opportunity to raise awareness about the disease and a rallying point for a concerted research effort to deal with the condition once and for all. It is still a year away, but now is the time to start planning events and building awareness. We would encourage you to mark 2017 as the year of Parkinson’s disease, share this with everyone you know, and endeavour to make some small effort to help in the fight against this condition.

Parkinson’s disease and the cancer drug

In October, 40,000 neuroscientists from all over the world gathered in Chicago for the annual Society for Neuroscience conference. It is one of the premier events on the ‘brain science’ calendar each year and only a few cities in the USA have the facilities to handle such a huge event.

 

agu20141212-16

Science conference. Source: JPL

During the five day neuroscience marathon, hundreds of lecture presentations were made and thousands of research poster were exhibited. Many new and exciting findings  were presented to the world for the first time, including the results of an interesting pilot study that has left everyone in the Parkinson’s research community very excited, but also scratching their heads.

The study (see the abstract here) was a small clinical trial (12 subjects; 6 month study) that was aiming to determine the safety and efficacy of a cancer drug, Nilotinib (Tasigna® by Novartis), in advanced Parkinson’s Disease and Lewy body dementia patients. In addition to checking the safety of the drug, the researchers also tested cognition, motor skills and non-motor function in these patients and found 10 of the 12 patients reported meaningful clinical improvements.

The study investigators reported that one individual who had been confined to a wheelchair was able to walk again; while three others who could not talk before the study began were able to hold conversations. They suggested that participants who were still in the early stages of the disease responded best, as did those who had been diagnosed with Lewy body dementia.

So what is Nilotinib?

Nilotinib (pronounced ‘nil-ot-in-ib’ and also known by its brand name Tasigna) is a small-molecule tyrosine kinase inhibitor, that has been approved for the treatment of imatinib-resistant chronic myelogenous leukemia (CML). That is to say, it is a drug that can be used to treat a type of leukemia when the other drugs have failed. It was approved for this treating cancer by the FDA in 2007.

The researchers behind the study suggest that Nilotinib works by turning on autophagy – the “garbage disposal machinery” inside each neuron. Autophagy is a process that clears waste and toxic proteins from inside cells, preventing them from accumulating and possibly causing the death of the cell.

Print

The process of autophagy – Source: Wormbook

Waste material inside a cell is collected in membranes that form sacs (called vesicles). These vesicles then bind to another sac (called a lysosome) which contains enzymes that will breakdown and degrade the waste material.


Some details about the study:

  • The study was run at the Georgetown University Medical Center
  • The patients were given increasing doses of Nilotinib (150mg to 300mg/day) that were are significantly lower than the doses of Nilotinib used for CML treatment (800-1200mg/day).
  • The researchers took cerebrospinal fluid (CSF; the liquid surrounding the brain) and blood samples at the start of the study, 2 and 6 months into the study.
  • Nilotinib was detected in the CSF, indicating that it had no problem crossing the protective blood-brain-barrier – the membrane covering the brain that blocks many drugs from entering.
  • Participants exhibited positive changes in various cerebrospinal fluid biomarkers with statistically significant changes in an important protein called, Tau, which have been shown to increase with the onset of dementia.
  • The researchers found a significant reduction (>60%) in levels of α-Synuclein detected in the blood, but no change in CSF levels of α-Synuclein. 
  • The investigators report that one individual confined to a wheelchair was able to walk again; three others who could not talk were able to hold conversations.

If the outcomes of this study are reproducible, then we here at the Science of Parkinson’s are assuming that Nilotinib is working by turning on the garbage disposal system of the remaining cells in the brain and allowing them to function better. This would suggest that there is a certain level of dysfunction in those remaining cells, which would be expected as this is a progressive disease. The study researchers reported that the small, daily dose of nilotinib turns on autophagy for about four to eight hours, and if that is enough to have such remarkable effects, then this treatment deserves more research.

The results of the study are intriguing and the participants of the study will continue to be treated and followed to see if the improvements continue.

BUT before we go getting too excited:

While these results sound extremely positive, there are several issues with this study that need to be considered before we celebrate the end of Parkinson’s disease.

Firstly, this study was an open-label trial – that means that everyone involved in the study (both researchers and subjects) knew what drug they were taking. There was also no control group or control treatment for comparative analysis in the study. Given these conditions there is always the possibility that what some of the subjects were experiencing was simply a placebo effect. Indeed the lead scientist on the project, Dr Fernando Pagan, pointed out that “It is critical to conduct larger and more comprehensive studies before determining the drug’s true impact.”

In addition, according to Novartis (the producer of the drug), the current cost of Nilotinib is about $10,360 (£6,900) per month for the daily 800mg dose used for cancer treatment. Even if the dose used in this study was only 150 to 300 mg/daily, it would still make this treatment extremely expensive. 

Thirdly, Nilotinib has a number of adverse side-effects when used as an anti-cancer drug (at 800mg/day). These include headache, fatigue, nausea, vomiting, diarrhea, constipation, muscle/joint pain, skin issues, flu-like symptoms, and reduced blood cell count. It may not be the nicest of treatments to tolerate.

There are important reasons for optimism, however, with the results of this study:

In 2010, a group of researchers published a paper demonstrating the neuroprotective effects of another cancer drug very similar to Nilotinib. That drug was ‘Gleevec’

Gleevec-PD1

Title: Phosphorylation by the c-Abl protein tyrosine kinase inhibits parkin’s ubiquitination and protective function.
Authors: Ko HS, Lee Y, Shin JH, Karuppagounder SS, Gadad BS, Koleske AJ, Pletnikova O, Troncoso JC,Dawson VL, Dawson TM.
Journal: Proc Natl Acad Sci U S A. 2010 Sep 21;107(38):16691-6.
PMID: 20823226

And that Gleevec publication was followed up a couple of years ago with a second study demonstrating the neuroprotective effects of another Abl-inhibitor: Nilotinib!

Gleevec-PD2

Title: The c-Abl inhibitor, nilotinib, protects dopaminergic neurons in a preclinical animal model of Parkinson’s disease.
Authors: Karuppagounder SS, Brahmachari S, Lee Y, Dawson VL, Dawson TM, Ko HS
Journal: Sci Rep. 2014 May 2;4:4874.
PMID: 24786396

These studies provided a strong rationale for testing brain permeable c-Abl inhibitors as potential therapeutic agents for the treatment of PD. The phase 2 trial at Georgetown will be starting in early 2016 and we will be watching this trial very closely.

“Red hair, sir, in my opinion, is dangerous”

Henna-Hair-Red-Hair-Ginger-Hair-Benefits-Beauty

The quote entitling this post is from a PG Wodehouse book ‘Very Good, Jeeves!’.


We have previously discussed the curious connection between melanoma and Parkinson’s disease. There is also a well known connection between melanoma and red hair. And believe it or not, there is another really strange relationship between Parkinson’s disease and red hair.

Redhair

Title: Genetic determinants of hair color and Parkinson’s disease risk.
Authors: Gao X, Simon KC, Han J, Schwarzschild MA, Ascherio A.
Journal: Ann Neurol. 2009 Jan;65(1):76-82.
PMID: 19194882

In 2009, researchers from Harvard University found a relationship between hair color and risk of Parkinson’s disease, when they examined the records of 131,821 US men and women who participated in the two large longitudinal studies, the Health Professionals Follow-up Study (HPFS) and the Nurses’ Health Study (NHS).


The HPFS, which started in 1986, sends questionnaires to US health professionals (dentists, optometrists, etc) – aged 40-75.  Every couple of years, members of the study receive questionnaires dealing with diseases and health-related issues (e.g. smoking, physical activity, etc). The questionnaire is supplemented by another questionnaires which is sent every four years, that deals with dietary information.

The NHS study – which was established in 1976 and then expanded in 1989 – has also collected questionnaire-based information from 238,000 registered nurses. Similar to the HPFS, every two years the study participants receive a questionnaire dealing with diseases and health-related topics.


In their study, the investigators found 264 of the male and 275 of the female responders to the HPFS and NHS questionnaires had been diagnosed with Parkinson’s disease. Of these individuals, 33 were black haired, 418 had brown hair, 62 were blond and 26 were redheads. Given that redheads make up just 1% of the general population but 5% of the people who were diagnosed with Parkinson’s disease in their study, the authors suggested that red haired people have a higher risk of developing Parkinson’s disease. Interestingly, they found a stronger association between hair color and Parkinson’s disease in younger-onset of PD (that is being diagnosed before 70 years of age) than those with age of onset greater than 70 years. When they took health and age related matters into account, the authors concluded that people with red hair are almost four times more likely to develop Parkinson’s disease than people with black hair.

NOTE: This result does not mean that people with red hair are definitely going to develop Parkinson’s disease, it simply suggests that they may be more vulnerable to the condition. And we should add that this result have never been replicated and we are not sure if anyone has ever attempted to reproduce it with a different database.

So how does (or could) this work?

The short answer is: we really don’t know.

The long answer involves explaining where there are no connections:

Red hair results from a genetic mutation. 80% of people with red hair have a mutation in a gene called MC1R – full name: melanocortin-1 receptor. Another gene associated with red hair is called HCL2 – ‘Hair colour 2’. We know that the connection between red hair and Parkinson’s disease is not genetic, as there is no association between MC1R mutations and Parkinson’s disease (for more on this, click here). We are not sure about HCL2, but this gene has never been associated with any disease.

What we do know is that redheads:

  • are more sensitive to cold (for more on this, click here)
  • are less responsive to subcutaneously (under the skin) administered anaesthetics (for more on this, click here)
  • suffer more from toothaches (for more on on this, click here)
  • are more sensitive to painkillers (for more on this, click here)
  • require more anesthetic for surgery (for more on this, click here)

Common myths associated with red hair include:

  • redheads bled more than others (this is not true – click here)…but they do bruise easier!
  • redheads are at greater risk of developing endometriosis (this is not true – click here)
  • redheads are more frequently left-handed (I can find no evidence for this, so I’ll put it in the myth basket until corrected).

There is also a strange link between red hair and multiple sclerosis, but it is too complicated to understand at the moment (women with red hair are more vulnerable to multiple sclerosis than men with red hair, for more on this, click here).

How any of these findings relates to Parkinson’s disease is unclear – we provide them here for those who are interested in following up this curious relationship.

One important caveat regarding this study is that incidence rates of Parkinson’s disease in countries with very high levels of red hair do not support the relationship (PD & red hair). In Scotland, approx. 10% of the population have red hair (source), and yet the England has a higher incidence of Parkinson’s disease (28.0/10,000 in England vs 23.9/10,000 in Scotland – source).

It may well be, however, that there is no direct connection between red hair and Parkinson’s disease. And until the results of the 2009 study mentioned above are replicated or supported by further findings, we here at the ‘Science of Parkinson’s disease’ shall consider this simply as a curious correlation.