Gene therapy involves treating medical conditions at the level of DNA – that is, altering or enhancing the genetic code inside cells to provide therapeutic benefits rather than simply administering drugs. Usually this approach utilises specially engineered viruses to deliver the new DNA to particular cells in the body.
For Parkinson’s, gene therapy techniques have all involved direct injections of these engineered viruses into the brain – a procedure that requires brain surgery. This year, however, we have seen the EXTREMELY rapid development of a non-invasive approach to gene therapy for neurological condition, which could ultimately see viruses being injected in the arm and then travelling up to the brain where they will infect just the desired population of cells.
Last week, however, this approach hit a rather significant obstacle.
In today’s post, we will have a look at this gene therapy technology and review the new research that may slow down efforts to use this approach to help to cure Parkinson’s.
Gene therapy. Source: rdmag
When you get sick, the usual solution is to visit your doctor.
They will prescribe a medication for you to take, and then all things going well (fingers crossed/knock on wood) you will start to feel better. It is a rather simple and straight forward process, and it has largely worked well for most of us for quite some time.
As the overall population has started to live longer, however, we have begun to see more and more chronic conditions which require long-term treatment regimes. The “long-term” aspect of this means that some people are regularly taking medication as part of their daily lives. In many cases, these medications are taken multiple times per day.
A good example of this is Levodopa (also known as Sinemet or Madopar) which is the most common treatment for the chronic condition of Parkinson’s disease.
When you swallow your Levodopa pill, it is broken down in the gut, absorbed through the wall of the intestines, transported to the brain via our blood system, where it is converted into the chemical dopamine – the chemical that is lost in Parkinson’s disease. This conversion of Levodopa increases the levels of dopamine in your brain, which helps to alleviate the motor issues associated with Parkinson’s disease.
Levodopa. Source: Drugs
This pill form of treating a disease is only a temporary solution though. People with Parkinson’s – like other chronic conditions – need to take multiple tablets of Levodopa every day to keep their motor features under control. And long term this approach can result in other complications, such as Levodopa-induced dyskinesias in the case of Parkinson’s.
Yeah, but is there a better approach?
In addition to looking at current Parkinson’s disease research on this website, I like to look at where technological advances are taking us with regards to future therapies.
In July of this year, I wrote about a new class of engineered viruses that could potentially allow us to treat conditions like Parkinson’s disease using a non-invasive, gene therapy approach (Click here to read that post). At the time I considered this technology way off at some point in the distant future. Blue sky research. “Let’s wait and see” – sort of thing.
So imagine my surprise when an Italian research group last weekend published a new research report in which they used this futurist technology to correct a mouse model of Parkinson’s disease. Suddenly the distant future is feeling not so ‘distant’.
In today’s post we will review and discuss the results, and look at what happens next.
Technological progress – looking inside the brain. Source: Digitial Trends
I have said several times in the past that the pace of Parkinson’s disease research at the moment is overwhelming.
So much is happening so quickly that it is quite simply difficult to keep up. Not just here on the blog, but also with regards to the ever increasing number of research articles in the “need to read” pile on my desk. It’s mad. It’s crazy. Just as I manage to digest something new from one area of research, two or three other publications pop up in different areas.
But it is the shear speed with which things are moving now in the field of Parkinson’s research that is really mind boggling!
Take for example the case of Squalamine.
In February of this year, researchers published an article outlining how a drug derived from the spiny dogfish could completely suppress the toxic effect of the Parkinson’s associated protein Alpha Synuclein (Click here to read that post).
The humble dogfish. Source: Discovery
And then in May (JUST 3 MONTHS LATER!!!), a biotech company called Enterin Inc. announced that they had just enrolled their first patient in the RASMET study: a Phase 1/2a randomised, controlled, multi-center clinical study evaluating a synthetic version of squalamine (called MSI-1436) in people with Parkinson’s disease. The study will enrol 50 patients over a 9-to-12-month period (Click here for the press release).
Wow! That is fast.
Yeah, I thought so too, but then this last weekend a group in Italy published new research that completely changed my ideas on the meaning of the word ‘fast’. Regular readers will recall that in July I discussed amazing new technology that may one day allow us to inject a virus into a person’s arm and then that virus will make it’s way up to the brain and only infect the cells that we want to have a treatment delivered to. This represents non-invasive (as no surgery is required), gene therapy (correcting a medical condition with the delivery of DNA rather than medication). This new study used the same virus we discussed in July.
This week a group of scientists have published an article which indicates differences between mice and human beings, calling into question the use of these mice in Parkinson’s disease research.
The results could explain way mice do not get Parkinson’s disease, and they may also partly explain why humans do.
In today’s post we will outline the new research, discuss the results, and look at whether Levodopa treatment may (or may not) be a problem.
The humble lab mouse. Source: PBS
Much of our understanding of modern biology is derived from the “lower organisms”.
From yeast to snails (there is a post coming shortly on a snail model of Parkinson’s disease – I kid you not) and from flies to mice, a great deal of what we know about basic biology comes from experimentation on these creatures. So much in fact that many of our current ideas about neurodegenerative diseases result from modelling those conditions in these creatures.
Now say what you like about the ethics and morality of this approach, these organisms have been useful until now. And I say ‘until now’ because an interesting research report was released this week which may call into question much of the knowledge we have from the modelling of Parkinson’s disease is these creatures.
You see, here’s the thing: Flies don’t naturally develop Parkinson’s disease.
Nor do mice. Or snails.
Or yeast for that matter.
So we are forcing a very un-natural state upon the biology of these creatures and then studying the response/effect. Which could be giving us strange results that don’t necessarily apply to human beings. And this may explain our long history of failed clinical trials.
We work with the best tools we have, but it those tools are flawed…
What did the new research report find?
This is the study:
Title: Dopamine oxidation mediates mitochondrial and lysosomal dysfunction in Parkinson’s disease
Authors: Burbulla LF, Song P, Mazzulli JR, Zampese E, Wong YC, Jeon S, Santos DP, Blanz J, Obermaier CD, Strojny C, Savas JN, Kiskinis E, Zhuang X, Krüger R, Surmeier DJ, Krainc D
Journal: Science, 07 Sept 2017 – Early online publication
The researchers who conducted this study began by growing dopamine neurons – a type of cell badly affected by Parkinson’s disease – from induced pluripotent stem (IPS) cells.
What are induced pluripotent stem cells?
This week pre-clinical data was published demonstrating that the Ambroxol is active in the brain.
This is important data given that there is currently a clinical trial being conducted for Ambroxol in Parkinson’s disease.
Today’s post will review the new data and discuss what is happening regarding the clinical trial.
Ambroxol. Source: Skinflint
We have previously discussed the potential use of Ambroxol in the treatment of Parkinson’s disease (Click here to read that post). Today we follow up that post with new data that provides further support for an on-going clinical trial.
Firstly, what is Ambroxol?
Ambroxol is a commonly used treatment for respiratory diseases (the respiratory system being the lungs and related components required for breathing). Ambroxol promotes the clearance of mucus and eases coughing. It also has anti-inflammatory properties, reducing redness in a sore throat. It is the active ingredient of products like Mucosolvan, Mucobrox, and Mucol.
What is the connection between Ambroxol and Parkinson’s disease?
So this is where a gene called GBA comes into the picture.
Genetic mutations in the GBA (full name: Glucosylceramidase Beta) gene are the most common genetic anomaly associated with Parkinson’s disease. People with a mutation in their GBA gene have a higher risk of developing Parkinson’s disease than the general population. And interestingly, people with Parkinson’s disease are approximately five times more likely to carry a GBA mutation than healthy control subjects.
What does GBA do?
The GBA gene provides the instructions for making an enzyme (called glucocerebrosidase) that helps with the digestion and recycling of waste inside cells. The enzyme is located and active inside ‘lysosomes‘.
What are Lysosomes?
Lysosomes are small bags of digestive enzymes that can be found inside cells. They help to break down proteins that have either been brought into the cell or that have served their function and need to be digested and disposed of (or recycled).
How lysosomes work. Source: Prezi
Inside the lysosomes are enzymes like glucocerebrosidase which help to break material down into useful parts. The lysosome will fuse with other small bags (called vacuole) that act as storage vessels of material inside a cell. The enzymes from the lysosome will mix with the material in the vacuole and digest it (or it break down into more manageable components).
Now people with a genetic mutation in their GBA gene will often have an abnormally short, non-functioning version of the glucocerebrosidase enzyme. In those cases the breaking down of waste inside the lysosome becomes inhibited. And if waste can’t be disposed of or recycled properly, things start to go wrong in the cell.
How does Ambroxol correct this?
It was recently shown that Ambroxol triggers exocytosis of lysosomes (Source). Exocytosis is the process by which waste is exported out of the cell.
Exocytosis. Source: Socratic
Thus by encouraging lysosomes to undergo exocytosis and spit their contents out of the cell – digested or not – Ambroxol allows the cell to remove waste effectively and therefore function in a more normal fashion. This mechanism of treatment seemingly bi-passes the faulty glucocerebrosidase digestion enzyme entirely.
Until recently, two important questions, however, have remained unanswered:
- Does Ambroxol enter the brain and have this function there?
- What are the consequences of long term Ambroxol use?
We now have an answer for question no. 1:
Title: Ambroxol effects in glucocerebrosidase and α-synuclein transgenic mice.
Authors: Migdalska-Richards A, Daly L, Bezard E, Schapira AH.
Journal: Ann Neurol. 2016 Nov;80(5):766-775.
PMID: 27859541 (This article is OPEN ACCESS if you would like to read it)
In this study, the researchers treated mice with Ambroxol for 12 days and then measured the level of glucocerebrosidase activity in the brain. They gave Ambroxol to three different groups of mice:
- a group of normal mice,
- a group of mice which had been genetically engineered with a specific mutation in their GBA gene (the heterozygous L444P mutation)
- a group of mice that produced human alpha synuclein (the protein closely associated with Parkinson’s disease).
When they looked at the level of glucocerebrosidase enzyme activity in normal mice, they found an increase of approximately 20% (in mice treated with 4mM Ambroxol). One curious finding was that this dose was the only dose that increase glucocerebrosidase activity (1, 3, and 5mM of Ambroxol had no effect). The investigators noted, however, a reduction in water drinking of mice receiving 5mM in their drinking water (maybe they didn’t like the taste of it!), suggesting that they were not getting as much Ambroxol as the 4mM group.
The 4mM level of of Ambroxol also increased glucocerebrosidase activity in the L444P mutation mice and the alpha-synuclein mice (which interestingly also has reduced levels of glucocerebrosidase activity). One important observation in the alpha synuclein mice was the finding that Ambroxol was able to reduce the levels of alpha synuclein in the cells, indicating better clearance of un-wanted excess of proteins.
These combined results suggested to the investigators that Ambroxol is entering the brain of mice (passing through the protective blood brain barrier) and able to be effective there. In addition, they did not witness any serious adverse effects of ambroxol administration in the mice – an observation made in other studies of Ambroxol in normal mice (Click here to read more about this).
These studies have been followed up by a dosing study in primates which was just published:
Title: Oral ambroxol increases brain glucocerebrosidase activity in a nonhuman primate.
Authors: Migdalska-Richards A, Ko WK, Li Q, Bezard E, Schapira AH.
Journal: Synapse. 2017 Mar 12. doi: 10.1002/syn.21967.
PMID: 28295625 (This article is OPEN ACCESS if you would like to read it)
In this study, the investigators analysed the effect of Ambroxol treatment on glucocerebrosidase activity in three healthy non-human primates. One subject was given an ineffective control solution vehicle, another subject received 22.5 mg/day of Ambroxol and the third subject received 100 mg/day of Ambroxol. They showed that daily administration 100 mg/day of Ambroxol results in increased levels of glucocerebrosidase activity in the brain (approximately 20% increase on average across different areas of the brain). Importantly, the 22.5 mg treatment did not result in any increase.
The investigators wanted to determine if the effect of Ambroxol was specific to glucocerebrosidase, and so they analysed the activity of another lysosome enzyme called beta-hexosaminidase (HEXB). They found that 100 mg/day of Ambroxol also increased HEXB activity (again by approximately 20%), suggesting that Ambroxol may be having an effect on other lysosome enzymes and not just glucocerebrosidase.
The researches concluded that these results provide the first data of the effect of Ambroxol treatment on glucocerebrosidase activity in the brain of non-human primates. In addition, the results indicate that Ambroxol is active and as the researchers wrote “should be further investigated in the context of clinical trials as a potential treatment for Parkinson’s disease”.
And there is a clinical trial currently underway?
Funded by the Cure Parkinson’s Trust and the Van Andel Research Institute (USA), there is currently a phase I clinical trial with 20 people with Parkinson’s disease receiving Ambroxol over 24 months. Importantly, the participants being enrolled in the study have both Parkinson’s disease and a mutation in their GBA gene. The study is being led by Professor Anthony Schapira at the Royal Free Hospital (London).
EDITORS NOTE HERE: Readers may be interested to know that Prof Schapira is also involved with another clinical trial for GBA-associated Parkinson’s disease. The work is being conducted in collaboration with the biotech company Sanofi Genzyme, and involves a phase II trial, called MOVE-PD, which is testing the efficacy, and safety of a drug called GZ/SAR402671 (Click here to read more about this clinical trial). GZ/SAR402671 is a glucosylceramide synthase inhibitor, which will hopefully reduce the production and consequent accumulation of glycosphingolipids in people with a mutation in the GBA gene. This approach is trying to reduce the amount of protein that can not be broken down by the faulty glucocerebrosidase enzyme. The MOVE-PD study will enroll more than 200 patients worldwide (Click here and here to read more on this).
The current Phase 1 trial at the Royal Free Hospital will be primarily testing the safety of Ambroxol in GBA-associated Parkinson’s disease. The researchers will, however, be looking to see if Ambroxol can increase levels of glucocerebrosidase and also assess whether this has any beneficial effects on the Parkinson’s features.
So what does it all mean?
There is a major effort from many of the Parkinson’s disease related charitable groups to clinically test available medications for their ability to slow this condition. Big drug companies are not interested in this ‘re-purposing effort’ as many of these drugs are no longer patent protected and thus providing limited profit opportunities for them. This is one of the unfortunate realities of the pharmaceutical industry business model.
One of the most interesting drugs being tested in this re-purposing effort is the respiratory disease-associated treatment, Ambroxol. Recently new research has been published that indicates Ambroxol is able to enter the brain and have an impact by increasing the level of protein disposal activity.
A clinical trial testing Ambroxol in Parkinson’s disease is underway and we will be watching for the results when they are released (most likely late 2019/early 2020, though preliminary results may be released earlier).
This trial is worth watching.
EDITOR’S NOTE: Under absolutely no circumstances should anyone reading this material consider it medical advice. The material provided here is for educational purposes only. Before considering or attempting any change in your treatment regime, PLEASE consult with your doctor or neurologist. Amboxol is a commercially available medication, but it is not without side effects (for more on this, see this website). We urge caution and professional consultation before altering a treatment regime. SoPD can not be held responsible for any actions taken based on the information provided here.
The banner for today’s post was sourced from Pharmacybook
The influence of genetics in Parkinson’s disease is difficult to determine. If it was simply a genetic disease, identical twins – who share identical DNA – should show no difference in their susceptibility to Parkinson’s disease. They should either both develop the condition, or not. Right?
But this is not the case.
In today’s post we will review a particularly interesting pair of identical twins.
Jeff & Jack Gernsheimer in 1982. Source: ReadingEagle
When people ask the obvious question about the cause of Parkinson’s disease – ‘is it genetics or is it environment?’ – I have a standard answer: ‘it’s complicated’. I then tell them the curious story of identical twins Jeff and Jack Gernsheimer from eastern Pennsylvania. No other case better demonstrates the strange question of what causes Parkinson’s disease.
For almost their entire lives (69 years), Jeff and Jack have lived no more than half a mile apart. Breathing the same air, drinking the same water. They are literally neighbours – just a five-minute walk between their homes. In addition, since 1971 they have worked in the same office at a graphic design firm that they started together. The brothers were the focus of a story in the online magazine Nautilus last year. It’s a fantastic article and I fully recommend you read it.
So here’s the thing: In 2009 Jack was diagnosed with Parkinson’s disease.
To date, Jeff is yet to exhibit any signs of the condition.
Two genetically identical people, living in the exact same environment and one of them develops Parkinson’s disease.
Ok, how do we explain this?
Hang on a second, slow down. I haven’t even got to the really interesting part yet:
After being diagnosed, Jack had his genome sequenced to see if there were any particular genetic mutations that might make him vulnerable to Parkinson’s disease. That analysis determined that Jack has a mutation in the most common Parkinson’s disease-associated gene: Glucocerebrosidase or GBA (which we have discussed in a previous blog post).
Interesting. So that explains the Parkinson’s disease?
No. Jack’s identical twin brother, Jeff, also has that exact same mutation.
So now we have a pair of identical twins who share the identical genetic code, live in the same environment, and have a genetic mutation associated with Parkinson’s disease, but only Jack has developed the condition while Jeff has not.
I think you will agree, it’s a really interesting tale… and with the help of modern science, it gets even more interesting.
In 2014, a research paper was published that utilized cells from both Jack & Jeff to determine what differences existed between them:
Title: iPSC-derived dopamine neurons reveal differences between monozygotic twins discordant for Parkinson’s disease.
Authors: Woodard CM, Campos BA, Kuo SH, Nirenberg MJ, Nestor MW, Zimmer M, Mosharov EV, Sulzer D, Zhou H, Paull D, Clark L, Schadt EE, Sardi SP, Rubin L, Eggan K, Brock M, Lipnick S, Rao M, Chang S, Li A, Noggle SA.
Journal: Cell Reports. 2014 Nov 20;9(4):1173-82.
PMID: 25456120 (this article is OPEN ACCESS if you would like to read it)
EDITOR’S NOTE HERE: Monozygotic means twins from the same egg, (as opposed to dizygotic meaning twins from two eggs). And discordant means ‘at variance, or at odds’ – in medicine it is used when one identical twin has a condition and the other does not.
The researchers conducting this study took skin cells from the brothers and they turned them into brain cells via a miraculous Nobel-prize winning approach. The technique firstly involves turning the skin cells into induced pluripotent stem cells (or iPS cells).
iPS cells can be used to make any cell you wish, and the researchers encouraged Jack and Jeff’s iPS cells to develop into dopamine neurons (one of the types of cells that are vulnerable in Parkinson’s disease).
When the researchers analysed the dopamine neurons from both twins, they found that both had half the normal levels GBA protein activity (an enzymatic reaction) due to the mutation in the GBA gene. The brother’s dopamine neurons also had approximately three times the normal levels of alpha-synuclein protein, and a reduced capacity to synthesize and release dopamine.
Dopamine neurons. Source: MindsofMalady
Then the researchers noticed something interesting: the dopamine cells from Jack (the affected twin) had lower dopamine levels than Jeff’s cells. This was rather strange: identical twins should actually have similar levels – all things being equal. The researchers attributed this decrease in dopamine to an increase in the levels of monoamine oxidase B (MAO-B) in Jack’s cells.
What is MAO-B?
Good question. MAO-B is an enzyme in dopamine neurons that helps to break down excess dopamine. After a cell releases dopamine, the cell will re-collect and recycle leftover/unused dopamine. MAO-B is the enzyme that breaks dopamine down. MAO-B inhibitors (such as Rasagiline or Azilect) have been used for some time as a therapy in Parkinson’s disease. By blocking MAO-B with MAO-B inhibitors, people with Parkinson’s disease can have increased levels of dopamine as the remaining dopamine does not get broken down so quickly.
The researchers studying Jack and Jeff’s iPS dopamine neurons found that by replacing the reduced GBA and inhibiting the oversupply of MAO-B (with MAO-B inhibitors) they made the dopamine neurons healthier – with an increase in dopamine levels and increased removal of excessive alpha-synuclein (the protein that is associated with Parkinson’s disease).
Are Jeff and Jack in a unique situation?
Nope. Not at all.
Here are some other examples:
Title: Pathology of PD in monozygotic twins with a 20-year discordance interval.
Author: Dickson D, Farrer M, Lincoln S, Mason RP, Zimmerman TR Jr, Golbe LI, Hardy J.
Journal: Neurology. 2001 Apr 10;56(7):981-2.
This was a case study in which a pair of identical twins both developed Parkinson’s disease, but one of the twins was diagnosed 20 years before the other.
Title: Identical twins with Leucine rich repeat kinase type 2 mutations discordant for Parkinson’s disease.
Authors: Xiromerisiou G, Houlden H, Sailer A, Silveira-Moriyama L, Hardy J, Lees AJ.
Journal: Movement Disord. 2012 Sep 1;27(10):1323.
PMID: 22488887 (This article is OPEN ACCESS if you would like to read it)
This second case study involved a pair of twins who both carried a mutation in the Parkinson’s associated gene, Lrrk2 (click here to read more about this gene). They both developed Parkinson’s disease, but 10 years separated their diagnoses.
Title: Parkinson disease in twins: an etiologic study.
Authors: Tanner CM, Ottman R, Goldman SM, Ellenberg J, Chan P, Mayeux R, Langston JW.
Journal: JAMA. 1999 Jan 27;281(4):341-6.
PMID: 9929087 (This article is OPEN ACCESS if you would like to read it)
In this study, the scientists screened 19,842 white male twins enrolled in the National Academy of Sciences/National Research Council World War II Veteran Twins Registry. 163 pairs of twin were identified in which at least 1 twin had Parkinson’s disease (and medical records were available).
When diagnosis was made over the age of 50 years of age, approximately 10% of the twin pairs both had Parkinson’s disease (for both monozygotic and dizygotic twins). But when diagnosis was made under the age of 50, the monozygotic concordance was 100% – that is, all of the identical twins diagnosed under the age of 50 had Parkinson’s disease – while the dizygotic concordance remained around 10-20%. The researchers concluded that ‘this pattern strongly supports a primarily inherited cause of early-onset Parkinson’s disease’.
So how do we explain the difference seen in Jack and Jeff?
Some twins may be born with a vulnerability for Parkinson’s disease (like a genetic mutation, in the GBA or Lrrk2 gene for example), but there is some other factor/s that is influential in the initiation of the disease. And this is where scientists start talking about something called epigenetics (Epi, Greek for ‘over’ or ‘above’ and Genetics,…well, you should be able to work that one out).
Epigenetics is the study of changes in an organism that are caused by modifications or variations of gene expression rather than alteration of the genetic code itself. These variations may result from external factors that cause genes to turn on and off.
In the case of the Gernsheimer twins, if you read the story in the online magazine Nautilus you will find that their lives were not entirely the same. There were basic differences, for examples they went to different universities and in the 1970’s Jack enlisted in the army. But there were also some larger, life-altering differences: in the late 1980’s Jack lost a son in tragic circumstances. The brothers speculate that the stress/suffering associated with that particular event may have been a catalyst for the Parkinson’s that followed. Many researchers in the Parkinson’s disease field have speculated on whether a stressful/traumatic event in their lives was the causative agent for their Parkinson’s disease.
So what does it all mean?
It means that the answer is more complicated than first assumed. And unfortunately, this is where I end up when people ask me about ‘genetics vs environment’ in the cause of Parkinson’s disease: a qualified we really don’t know. But I do always suggest that ‘Genetics vs environment’ may be too simplistic.
The source of today’s banner was the AutismBlog.