Handling unstable analytes: literature review and expert panel survey by Japan Bioanalysis Forum Discussion Group

Analyzing unstable small molecule drugs and metabolites in blood continues to be challenging for bioanalysis. Although scientific countermeasures such as immediate cooling, immediate freezing, addition of enzyme inhibitors, pH adjustment, dried blood spot or derivatization have been developed, selecting the best practices has become an issue in the pharmaceutical industry as the number of drugs with such problems is increasing, even for generic drugs. In this study, we conducted a comprehensive literature review and a questionnaire survey to determine a suitable practice for evaluating instability and implementing countermeasures. Three areas of focus, matrix selection, effect of hemolysis and selection of esterase inhibitors, are discussed.

Multi-Target-Directed Ligands as an Effective Strategy for the Treatment of Alzheimer’s Disease

Alzheimer’s disease (AD) is a complex neurological disorder, and multiple pathological factors are believed to be involved in the genesis and progression of the disease. A number of hypotheses, including Acetylcholinesterase, Monoamine oxidase, β-Amyloid, Tau protein, etc., have been proposed for the initiation and progression of the disease. At present, acetylcholine esterase inhibitors and memantine (NMDAR antagonist) are the only approved therapies for the symptomatic management of AD. Most of these single-target drugs have miserably failed in the treatment or halting the progression of the disease. Multi-factorial diseases like AD require complex treatment strategies that involve simultaneous modulation of a network of interacting targets. Since the last few years, Multi-Target-Directed Ligands (MTDLs) strategy, drugs that can simultaneously hit multiple targets, is being explored as an effective therapeutic approach for the treatment of AD. In the current review article, the authors have briefly described various pathogenic pathways associated with AD. The importance of Multi-Target-Directed Ligands and their design strategies in recently reported articles have been discussed in detail. Potent leads are identified through various structure-activity relationship studies, and their drug-like characteristics are described. Recently developed promising compounds have been summarized in the article. Some of these MTDLs with balanced activity profiles against different targets have the potential to be developed as drug candidates for the treatment of AD.

Influence of Acetylcholine Esterase Inhibitors and Memantine, Clinically Approved for Alzheimer’s Dementia Treatment, on Intestinal Properties of the Mouse

Four drugs are currently approved for the treatment of Alzheimer’s disease (AD) by the FDA. Three of these drugs—donepezil, rivastigmine, and galantamine—belong to the class of acetylcholine esterase inhibitors. Memantine, a NMDA receptor antagonist, represents the fourth and a combination of donepezil and memantine the fifth treatment option. Recently, the gut and its habitants, its microbiome, came into focus of AD research and added another important factor to therapeutic considerations. While the first data provide evidence that AD patients might carry an altered microbiome, the influence of administered drugs on gut properties and commensals have been largely ignored so far. However, the occurrence of digestive side effects with these drugs and the knowledge that cholinergic transmission is crucial for several gut functions enforces the question if, and how, this medication influences the gastrointestinal system and its microbial stocking. Here, we investigated aspects such as microbial viability, colonic propulsion, and properties of enteric neurons, affected by assumed intestinal concentration of the four drugs using the mouse as a model organism. All ex vivo administered drugs revealed no direct effect on fecal bacteria viability and only a high dosage of memantine resulted in reduced biofilm formation of E. coli. Memantine was additionally the only compound that elevated calcium influx in enteric neurons, while all acetylcholine esterase inhibitors significantly reduced esterase activity in colonic tissue specimen and prolonged propulsion time. Both, acetylcholine esterase inhibitors and memantine, had no effect on general viability and neurite outgrowth of enteric neurons. In sum, our findings indicate that all AD symptomatic drugs have the potential to affect distinct intestinal functions and with this—directly or indirectly—microbial commensals.

Pronounced Ptosis in Myasthenia Gravis—A New Bedside Clinical Sign

We report three cases of myasthenia gravis in whom the asymmetrical ptosis at presentation became more pronounced with the described bedside technique. Pronounced ptosis could be elicited by making the patient speak continuously for up to 2 minutes. Pauses for breathing and natural blinking were allowed. The sign is best elicited in newly diagnosed and treatment-naive patients. The loss of compensation for ptosis by frontalis muscle due to speech-induced fatigue may be responsible for the observed effect. Patients’ symptoms abated on treatment with acetylcholine esterase inhibitors, steroids, and steroid-sparing agents.

Stability of Ketoprofen Methylester in Plasma of Different Species

Background: Pharmacokinetic and pharmacodynamic assessment of ester-containing drugs can be impacted by hydrolysis of the drugs in plasma samples post blood collection. The impact is different in the plasma of different species. Objective: This study was to evaluate stability of a prodrug, ketoprofen methylester (KME) in commercially purchased and freshly collected plasma of mouse, rat, dog, cat, pig, sheep, cattle and horse. Methods: KME hydrolysis was determined following its incubation in commercially purchased and freshly collected plasma of those species. Different esterase inhibitors were evaluated for prevention of the hydrolysis in rat, dog and pig plasma. Results: KME was rapidly hydrolyzed in both commercially purchased and freshly collected plasma of mouse, rat, and horse. The hydrolysis was initially quick and then limited in cat plasma. KME hydrolysis was minimum in commercially purchased plasma of dog, pig, sheep and cattle but substantial in freshly collected plasma of those species. Different esterase inhibitors showed different effects on stability of KME in rat, dog and pig plasma. Conclusion: These results indicate that plasma of different species has different hydrolytic activities to ester-containing drugs. The activities in commercially purchased and freshly collected plasma may be different and species dependent. Esterase inhibitors have different effects on prevention of hydrolysis of the ester-containing drugs in the plasma of different species.

The Lewy body dementias

Dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD) belong to the α‎-synucleinopathies, a family of diseases pathologically characterized by aggregation of α‎-synuclein in Lewy bodies in the brain. This chapter presents the epidemiological data for both conditions including new data on MCI. It reviews clinical diagnostic criteria and considers the different neuropathology staging systems for DLB and PDD and the most important genetic findings. It describes biomarkers in DLB and PDD with particular focus on imaging techniques like CIT-SPECT and MRI. It presents in detail important clinical symptoms in both conditions and discusses the most important clinical differential diagnoses. Finally, it examines pharmacological and non- pharmacological treatment of different symptoms in both conditions, with particular emphasis on the choline esterase inhibitors and antipsychotic medications, and presents new data on memantine.

The Inhibition of Complement System in Formal and Emerging Indications: Results from Parallel One-Stage Pairwise and Network Meta-Analyses of Clinical Trials and Real-Life Data Studies

This manuscript presents quantitative findings on the actual effectiveness of terminal complement component 5 (C5) inhibitors and complement component 1 (C1) esterase inhibitors through their formal and common “off-label” (compassionate) indications. The results emanated from pairwise and network meta-analyses to present evidence until September 2019. Clinical trials (CT) and real-life non-randomized studies of the effects of interventions (NRSI) are consistent on the benefits of C5 inhibitors and of the absence of effects of C1 esterase inhibitors (n = 7484): Mathematically, eculizumab (surface under the cumulative ranking area (SUCRA) >0.6) and ravulizumab (SUCRA ≥ 0.7) were similar in terms of their protective effect on hemolysis in paroxysmal nocturnal hemoglobinuria (PNH), thrombotic microangiopathy (TMA) in atypical hemolytic uremic syndrome (aHUS), and acute kidney injury (AKI) in aHUS, in comparison to pre-/off-treatment state and/or placebo (SUCRA < 0.01), and eculizumab was efficacious on thrombotic events in PNH (odds ratio (OR)/95% confidence interval (95% CI) in CT and real-life NRSI, 0.07/0.03 to 0.19, 0.24/0.17 to 0.33) and chronic kidney disease (CKD) occurrence/progression in PNH (0.31/0.10 to 0.97, 0.66/0.44 to 0.98). In addition, meta-analysis on clinical trials shows that eculizumab mitigates a refractory generalized myasthenia gravis (rgMG) crisis (0.29/0.13 to 0.61) and prevents new acute antibody-mediated rejection (AMR) episodes in kidney transplant recipients (0.25/0.13 to 0.49). The update of findings from this meta-analysis will be useful to promote a better use of complement inhibitors, and to achieve personalization of treatments with this class of drugs.