US20190350898A1 - Methods and compositions for treatment of alzheimer's disease - Google Patents

Methods and compositions for treatment of alzheimer's disease Download PDF

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US20190350898A1
US20190350898A1 US16/414,878 US201916414878A US2019350898A1 US 20190350898 A1 US20190350898 A1 US 20190350898A1 US 201916414878 A US201916414878 A US 201916414878A US 2019350898 A1 US2019350898 A1 US 2019350898A1
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bryostatin
sib
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Daniel L. Alkon
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Neurotrope Bioscience Inc
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/335—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin
    • A61K31/365—Lactones
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K9/00—Medicinal preparations characterised by special physical form
    • A61K9/0012—Galenical forms characterised by the site of application
    • A61K9/0019—Injectable compositions; Intramuscular, intravenous, arterial, subcutaneous administration; Compositions to be administered through the skin in an invasive manner
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/28—Drugs for disorders of the nervous system for treating neurodegenerative disorders of the central nervous system, e.g. nootropic agents, cognition enhancers, drugs for treating Alzheimer's disease or other forms of dementia
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K14/00—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • C07K14/435—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • C07K14/475—Growth factors; Growth regulators
    • C07K14/49—Platelet-derived growth factor [PDGF]
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides

Definitions

  • AD Alzheimer's disease
  • Other therapeutic strategies have focused on enhancement or blockade of neurotransmitters at synaptic junctions (Reisberg et al. N Engl J Med. 2003 Apr. 3; 348(14):1333-41). While the latter have generated drugs with some symptomatic efficacy, the approved drugs have thus far not been effective in preventing, improving, and/or reversing the progressive neurodegeneration that ultimately causes major cognitive dysfunction and functional decline in AD patients (Farlow et al., Clin. Ther. 2010 July; 32(7):1234-51.
  • AD cognitive deficits have been shown to correlate closely with the loss of synapses as measured directly or indirectly at autopsy (Terry et al., Ann Neurol. 1991 October; 30(4):572-80).
  • An effective therapeutic for AD should be directed toward, not only the causes, but also the consequences of the characteristic progressive neurodegeneration. Based on the synaptic loss in AD, there would be a significant benefit in a therapeutic strategy that can restore lost synapses in AD brains.
  • AD Alzheimer's disease
  • PKC protein kinase C
  • the PKC activator is bryostatin or analog thereof.
  • the PKC activator is bryostatin-1.
  • Methods of treating Alzheimer's disease are also described herein including administering to an AD patient in need thereof a PKC activator, wherein the treatment excludes administration of a NMDA receptor antagonist.
  • the PKC activator is bryostatin or analog thereof.
  • the PKC activator is bryostatin-1.
  • Methods of treating Alzheimer's disease are also described herein including administering to an AD patient in need thereof bryostatin-1 wherein the patient is not also administered memantine.
  • Methods of treating Alzheimer's disease are also described herein including administering to an AD patient in need thereof no more than or less than about 30, 35, or 40 mcg (or range therein) of bryostatin-1 wherein the patient is not also administered memantine.
  • the patient is administered less than 40 mcg bryostatin-1.
  • the patient is administered about 20 mcg bryostatin-1.
  • Methods of treating Alzheimer's disease are also described herein including administering to an AD patient in need thereof about 20 mcg or 25 mcg (or range therein) of bryostatin-1 wherein the treatment excludes memantine.
  • Methods of treating Alzheimer's disease are also described herein including administering to an AD patient in need thereof no more than or less than about 30, 35, or 40 mcg (or range therein) of bryostatin-1 wherein the patient is not receiving memantine treatment.
  • the patient is administered 15-40 mcg bryostatin-1.
  • the patient is administered less than 40 mcg bryostatin-1
  • Methods of treating Alzheimer's disease are also described herein including administering to an AD patient in need thereof about 20 mcg or 25 mcg (or range therein) of bryostatin-1 wherein the patient is not receiving memantine treatment. In some embodiments the patient is administered about 20 mcg bryostatin-1.
  • Methods of treating Alzheimer's disease are also described herein including administering to an AD patient in need thereof about 15 mcg to about 25 mcg (or range therein) of bryostatin-1 wherein the treatment excludes memantine and provides cognitive improvement.
  • the patient is administered about 20 mcg bryostatin-1.
  • Methods of treating Alzheimer's disease are also described herein including administering to a patient in need thereof about 20 mcg or 25 mcg (or range therein) of bryostatin-1 wherein the treatment excludes memantine and is provided for at least or more than 4, 5, or 6 weeks.
  • Each of the methods described herein may further include the administration of a compound selected from the group consisting of galantamine, donepezil, rivastigimine, physostigmine, tacrine, huperzine A, ladostigil, and combinations thereof.
  • the patient in need of treatment is a patient diagnosed with mild Alzheimer's disease. In other embodiments, the patient is diagnosed with mild to moderate Alzheimer's disease.
  • the patient in need of treatment is a patient diagnosed with moderate Alzheimer's disease. In other embodiments, the patient is diagnosed with moderate to severe Alzheimer's disease. In other embodiments, the patient in need of treatment is a patient diagnosed with severe Alzheimer's disease.
  • the patient is diagnosed with early onset Alzheimer's disease. In other embodiments, the patient is diagnosed with late onset Alzheimer's disease.
  • compositions for treating Alzheimer's Disease include at least one PKC activator, the composition being free of any NMDA receptor antagonist.
  • the PKC activator is bryostatin or an analogue thereof.
  • the PKC activator is bryostatin-1.
  • the compositions are free of memantine.
  • FIG. 1 includes graphs showing the SIB change from baseline compared to placebo for the modified intent-to-treat (mITT) population and also the Completers population treated with Bryostatin.
  • FIG. 2 is a graph showing the SIB change from baseline compared to placebo 30 days post dosing in the mITT population.
  • FIG. 3 is a graph showing the SIB change from baseline compared to placebo 30 days post dosing in the Completers population.
  • FIG. 4 includes graphs showing the SIB change from baseline compared to placebo for the mITT population treated with bryostatin with or without memantine.
  • FIG. 5 includes graphs showing the SIB change from baseline compared to placebo for the Completers population treated with bryostatin with or without memantine.
  • FIG. 6 includes graphs showing the ADCS-ADL-SIV efficacy in the mITT population and the Completers population.
  • FIG. 7 includes graphs showing the sustained improvement of the SIB versus baseline and placebo 30 days post dosing in the Completers population.
  • FIG. 8 is a graph showing the Body Surface Area analysis of a bryostatin dose.
  • the present disclosure provides methods for treating Alzheimer's disease using PKC activators in the absence of any NMDA receptor antagonist, such as memantine.
  • protein kinase C activator i.e., “PKC activator” refers to a substance that increases the rate of the reaction catalyzed by protein kinase C, upregulates the expression of PKC (e.g., upregulates the expression of PKC ⁇ , PKC ⁇ II, PKC ⁇ and/or PKC ⁇ ), or otherwise facilitates the activation of PKC.
  • the PKC activator may be any of bryostatins 1-20, a bryolog, neristatin, a polyunsaturated fatty acid, or a combination of two or more of any of the foregoing substances.
  • NMDA receptor antagonist refers to a substance that antagonizes (i.e., inhibits) the action of NMDA receptors.
  • NMDA receptor antagonists include memantine, drug combinations containing memantine, dextromethorphan, ketamine, phencyclidine (PCP), methoxetamine (MXE), and nitrous oxide (N 2 O). Any one or all of the foregoing NMDA receptor antagonists may be excluded from the method of treating AD.
  • the present disclosure provides methods comprising administering to a human subject with Alzheimer's disease a pharmaceutically effective amount of a PKC activator without administering any NMDA receptor antagonist, such as memantine.
  • the PKC activator may be administered as part of a composition suitable for administration to a human subject.
  • the compositions used in the methods of the present disclosure may be administered via any suitable route, such as, for example, orally, intraperitoneally, subcutaneously, intranasally, buccally, trans-dermally intramuscularly, intrarectally, intravenously, or by oral inhalation.
  • the present disclosure provides methods comprising administering to a human subject with Alzheimer's disease a composition consisting essentially of, or containing exclusively, a pharmaceutically effective amount of a PKC activator in a pharmaceutically suitable carrier, optionally along with one or more pharmaceutically inactive auxiliary agents.
  • a composition consisting essentially of, or containing exclusively, a pharmaceutically effective amount of a PKC activator in a pharmaceutically suitable carrier, optionally along with one or more pharmaceutically inactive auxiliary agents.
  • the composition preferably does not include a second active agent, particularly a NMDA receptor antagonist.
  • Compositions and methods consisting essentially of a PKC activator exclude additional active compounds, such as memantine.
  • Bryostatins in particular, may be used as a PKC activator in the methods of the present disclosure.
  • the term “bryostatins” is herein meant to also include the numerous known analogues thereof, unless otherwise specified.
  • the bryostatins are a family of naturally occurring macrocyclic compounds originally isolated from marine bryozoa. Currently, there are about 20 known natural bryostatins which share three six-membered rings designated A, B and C, and which differ mainly in the nature of their substituents at C7 (OR A ) and C20 (R B ).
  • a representative generic structure of the bryostatins is provided below:
  • bryostatin 1 and analogues (derivatives) of bryostatin 1 are described in U.S. Pat. No. 4,560,774, the contents of which are herein incorporated by reference in their entirety.
  • Some examples of bryostatins that may be used as a PKC activator in methods of the present disclosure include bryostatin 1, bryostatin 2, bryostatin 3, bryostatin 4, bryostatin 5, bryostatin 6, bryostatin 7, bryostatin 8, bryostatin 9, bryostatin 10, bryostatin 11, bryostatin 12, bryostatin 13, bryostatin 14, bryostatin 15, bryostatin 16, bryostatin 17 bryostatin 18, bryostatin 19, and bryostatin 20.
  • Analogues of bryostatins may or may not be used in the methods of the present disclosure.
  • Bryologs are structural analogues of bryostatin. While bryostatin has two pyran rings and one 6-membered cyclic acetal, in most bryologs one of the pyrans of bryostatin is replaced with a second 6-membered acetal ring. This modification reduces the stability of bryologs, relative to bryostatin, for example, in both strong acid or base, but has little significance at physiological pH.
  • Bryologs also have a lower molecular weight (ranging from about 600 to 755), as compared to bryostatin (988), a property which may facilitate transport across the blood-brain barrier.
  • suitable bryologs include, but are not limited to analogs and derivatives of bryostatins, such as those described in U.S. Pat. Nos. 6,624,189, 7,256,286 and 8,497,385, the disclosures of which are incorporated herein by reference in their entirety.
  • PKC activators include potassium channel activators, such as, for example, diazoxide.
  • neristatins such as neristatin 1
  • Other suitable PKC activators include, but are not limited to, phorbol-12-myristate-13-acetate (PMA), okadaic acid, 1 ⁇ ,25-dihydroxyvitamin D3, 12-deoxyphorbol-13-acetate (prostratin), 1,2-dioctanoyl-sn-glycerol (DOG), 1-oleoyl-2-acetyl-sn-glycerol (OAG), (2S,5S)-(E,E)-8-(5-(4-(trifluoromethyl)phenyl)-2,4-pentadienoylamino)benzolactam ( ⁇ -amyloid precursor protein modulator), cis-9-octadecenoic acid (ole), phorbol-12-myristate-13-acetate (PMA), okad
  • any of the above bryologs, potassium channel activators, or neristatins may be excluded from the method.
  • any of the above bryologs, potassium channel activators, or neristatins may be used in combination with one or more bryostatins in the method described above.
  • a pharmaceutically effective amount is an amount of a pharmaceutical compound or composition having a therapeutically relevant effect on Alzheimer's disease.
  • a therapeutically relevant effect typically relates to or is evidenced by at least some improvement in a biomechanical process (e.g., gait, use of limbs, and the like) or a change in the cellular, physiological or biochemical parameters associated with any of the causes of Alzheimer's disease.
  • a therapeutically relevant effect may also be evident in an improved cognitive ability, such as short-term memory or problem solving.
  • the PKC activator is typically within a pharmaceutically acceptable carrier (i.e., diluent) when administered.
  • a pharmaceutically acceptable carrier i.e., diluent
  • pharmaceutically acceptable generally refers to those compounds, materials, compositions, and/or dosage forms that are, within the scope of sound medical judgment, suitable for entering a living organism or living biological tissue, preferably without significant toxicity, irritation, or allergic response.
  • the pharmaceutical compositions of the present invention may be formulated for administration in liquid or solid form.
  • the compound is generally dispersed in the physiologically acceptable carrier, by being dissolved or emulsified in a liquid carrier, or mixed (i.e., blended or compounded) with a solid carrier.
  • aqueous and non-aqueous carriers examples include, for example, water, ethanol, polyols (such as glycerol, propylene glycol, polyethylene glycol, and the like), vegetable oils (such as olive oil), injectable organic esters (such as ethyl oleate), and suitable mixtures thereof.
  • the pharmaceutical formulation may be formulated for oral administration (e.g., as tablets, capsules, powders, granules, pastes, solutions, suspensions, drenches, or syrups); parenteral administration (e.g., by subcutaneous, intramuscular or intravenous injection as provided by, for example, a sterile solution or suspension); sublingual or buccal administration; transdermal administration; or nasal administration.
  • oral administration e.g., as tablets, capsules, powders, granules, pastes, solutions, suspensions, drenches, or syrups
  • parenteral administration e.g., by subcutaneous, intramuscular or intravenous injection as provided by, for example, a sterile solution or suspension
  • sublingual or buccal administration e.g., by subcutaneous, intramuscular or intravenous injection as provided by, for example, a sterile solution or suspension
  • transdermal administration e.g., transdermal administration
  • nasal administration e.g., as tablets, capsules
  • the pharmaceutical composition may also include one or more pharmaceutically inactive auxiliary agents, such as pH buffering agents; sugars (e.g., lactose, glucose, sucrose, and oligosaccharides, such as sucrose, trehalose, lactose, or dextran); antimicrobials; and/or sweetening, flavoring, or coloring agents.
  • pharmaceutically inactive auxiliary agents such as pH buffering agents; sugars (e.g., lactose, glucose, sucrose, and oligosaccharides, such as sucrose, trehalose, lactose, or dextran); antimicrobials; and/or sweetening, flavoring, or coloring agents.
  • a pharmaceutically effective amount for bryostatins and/or bryologs may be from about 0.0000001 to about 5.00 mcg per kg host body weight per day, which can be administered in single or multiple doses.
  • the dosage level may be: from about 0.0000001 mcg/kg to about 2.50 mcg/kg per day; from about 0.0000005 mcg/kg to about 1.00 mcg/kg per day; from at least about 0.0000001 mcg/kg to about 2.50 mcg/kg per day; from at least about 0.00000005 mcg/kg to about 1.00 mcg/kg per day; from at least about 0.000001 mcg/kg to about 5.0 mcg/kg per day; or from about 0.00001 mcg/kg to about 5.0 mcg/kg per dose.
  • the dosage may be about 0.00000001 mcg/kg to about 0.00005 mcg/kg; 0.00005 mcg/kg to about 0.05 mcg/kg; about 0.0005 mcg/kg to about 5.0 mcg/kg per day; about 0.0001 mcg/kg to about 0.5 mcg/kg per dose; or 0.001 to 0.25 mcg/kg per dose.
  • a pharmaceutically effective amount of a PKC activator may be an amount ranging from about 1 mcg to about 500 meg per dose, or more particularly, from about 5 mcg to about 200 mcg per dose, or more particularly, from about 10 mcg to about 100 mcg per dose, or more particularly, from about 20 mcg to about 40 meg per dose.
  • the PKC activator is administered in an amount of precisely or about 10, 15, 20, 25, 30, 35, 40, 45, or 50 mcg, or in an amount within a range bounded by any two of the foregoing values, wherein the term “about” generally indicates no more than ⁇ 10% or ⁇ 5% from a given value.
  • the dosing is from about 1 ⁇ g/kg (3-25 ⁇ g/ m2 ) to 120 ⁇ g/kg (360-3000 ⁇ g/m 2 ). In other embodiments, the dosing is from about 0.04-0.3 ⁇ g/kg (1 ⁇ g/m 2 ) to about 1-10 ⁇ g/kg (25 ⁇ g/m 2 ). In other embodiments, the dosing is from about 0.01 ⁇ g/m 2 to about 25 ⁇ g/m 2 . In other embodiments, the dosing is from about 0.0002-0.0004 ⁇ g/kg to about 0.05-1 ⁇ g/kg.
  • the PKC activator is a bryostatin or analogue thereof and a pharmaceutically effective amount of the bryostatin or analogue thereof may be an amount ranging from about 1 mcg to about 500 mcg per dose, or more particularly, from about 5 mcg to about 200 mcg per dose, or more particularly, from about 10 mcg to about 100 mcg per dose, or more particularly, from about 20 mcg to about 40 mcg per dose.
  • the PKC activator is a bryostatin or analogue thereof administered at a dosage of about 0.001 to 100 mcg/kg; 0.01 to about 50 mcg/kg, about 0.1 to about 10 mcg/kg.
  • the PKC activator is a bryostatin or bryolog
  • the bryostatin or bryolog is used (administered) in an amount from about 0.0001 to about 1000 micrograms.
  • the bryostatin or bryolog is used in an amount of at least or about 0.0001, 0.0005, 0.001, 0.002, 0.003, 0.004, 0.005, 0.006, 0.007, 0.008, 0.009, 0.01, 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 5.0, 10.0, 15.0, 20.0, 25.0, 50.0, 75.0, 100.0, 150.0, 200.0, 250.0, 300.0, 400.0, 500.0, 600.0, 750.0, 800.0, 900.0, or 1000.0 micrograms, or an amount within a range bounded by any two of the for
  • the PKC activator present in the compositions used in the methods of the present disclosure is a bryostatin or bryolog, and the bryostatin or bryolog is used (administered) in an amount of less that 50 micrograms (i.e., 50 mcg, or 50 ⁇ g). In some embodiments, the bryostatin or bryolog is used in an amount of less than 45 mcg. In some embodiments, the bryostatin or bryolog is used in an amount of less than 40 mcg (40 ⁇ g). In other embodiments, the bryostatin or bryolog is used in an amount of less than 30 meg ( ⁇ g). In further embodiments to any of the foregoing embodiments, a lower limit of at least or above 1, 2, 3, 4, 5, 10, 15, 20, or 25 mcg may be used.
  • the pharmaceutical composition will include bryostatin (e.g., bryostatin-1) in an amount of 0.1 mcg to 50 mcg, 0.1 mcg to 25 mcg, 0.1 mcg to 20 mcg, 0.1 mcg to 15 mcg, 0.5 mcg to 50 mcg, 0.5 mcg to 25 mcg, 0.5 mcg to 20 mcg, 0.5 to 15 mcg, 1 mcg to 50 mcg, 1 mcg to 25 mcg, 1 mcg to 20 mcg, 1 mcg to 15 mcg, 1.5 mcg to 50 mcg, 1.5 mcg to 25 mcg, 1.5 mcg to 20 mcg, 1.5 mcg to 15 mcg, 2 mcg to 50 mcg, 2 mcg to 25 mcg, 2 mcg, 1.5
  • the pharmaceutical composition include bryostatin (e.g., bryostatin-1) in an amount of 5 mcg to 20 mcg, 5 mcg to 10 mcg, 4 mcg to 6 mcg, 6 mcg to 8 mcg, 8 mcg to 10 mcg, 10 mcg to 12 mcg, 12 mcg to 14 mcg, 14 mcg to 16 mcg, 16 mcg to 18 mcg, or 18 mcg to 20 mcg.
  • bryostatin e.g., bryostatin-1
  • the pharmaceutical composition include bryostatin (e.g., bryostatin-1) in an amount of 5 mcg to 20 mcg, 5 mcg to 10 mcg, 4 mcg to 6 mcg, 6 mcg to 8 mcg, 8 mcg to 10 mcg,
  • the pharmaceutical compositions used in the methods include bryostatin (e.g., bryostatin-1) in an amount of 0.1 mcg, 0.25 mcg, 0.5 mcg, 1 mcg, 2.5 mcg, 3 mcg, 4 mcg, 5 mcg, 7 mcg, 7.5 mcg, 10 mcg, 12.5 mcg, 15 mcg, 17.5 mcg, or 20 mcg.
  • any of the foregoing amounts may also serve as a dosage, which may be administered, for example, once or twice per day, or by any other suitable regime as discussed above.
  • compositions used in the methods of the present disclosure may be administered by any suitable regimen, such as a regimen of 1 to 4 times per day.
  • the compositions are administered twice a week, once a week, once every two weeks, once every three weeks, once every four weeks, once every six weeks, once every eight weeks or less or more frequently depending on the needs of the patient.
  • the compositions used in the methods of the present disclosure may be administered as part of a course of treatment lasting for about 1 to about 30 days; about 1 to about 90 days; about 1 to about 120 days; about 1 to about 180 days; about 1 to 365 days; one year; two years; three years; or for the patient's lifetime.
  • compositions used in the methods of the present disclosure may be administered as part of a course of treatment lasting for at least about 5 weeks; at least about 9 weeks; at least about 13 weeks; at least about 15 weeks.
  • specific dose level and frequency of dosage for any particular host may be varied and will depend upon a variety of factors, including the activity of the specific compound employed, the metabolic stability and length of action of that compound, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, the nature of the disorder, the severity of the particular disorder, and the host undergoing therapy.
  • SIB Severe Impairment Battery
  • the two 24 ⁇ g doses were followed by 20 ⁇ g doses at weeks 5, 7, 9 and 11 with the Severe Impairment Battery (SIB) measured at baseline and weeks 5, 9, 13, and 15.
  • SIB Severe Impairment Battery
  • the two 48 ⁇ g doses at weeks 0 and 1 were followed by 40 ⁇ g doses at weeks 5, 7, 9, and 11 with the SIB measured at baseline and weeks 5, 9, 13, and 15.
  • the subjects were stratified by MMSE-2 in two strata: Stratum 1 (4-9) and Stratum 2 (10-15).
  • the first primary endpoint was safety and tolerability, assessed by treatment emergent adverse events (TEAEs) with a sample size of 150 subjects randomized 1:1:1.
  • a secondary efficacy endpoint was ADCS-ADL Sev.
  • the primary safety population included all subjects who received at least 1 dose of study drug, and efficacy was evaluated in a modified intent to treat (mITT) population that received at least 1 dose of study drug and had at least one treatment evaluation.
  • Efficacy was evaluated both as a primary end-point in the modified intent-to-treat (mITT) population and also as a primary end point in a Completers population that included all patients that completed the entire protocols as described above.
  • MMRM mixed model for repeat measures
  • the correlations between visits were generally not as strong in the 40 ⁇ g group (found to produce no SIB improvement) at any of the visits.
  • the correlations and p-values for the change scores for SIB (and ADC—poor between-group) for the 20 ⁇ g group are given in Table 1 below.
  • Week 15 results were only included for subjects who were not re-randomized.
  • the mixed model assumes missing at random, but order of enrollment in the trial was not random. Since order of enrollment was not random, the assumption of missing at random is not met. For this reason, only including week 15 for those who were not re-randomized is an appropriate way to estimate week 15 results, but not an appropriate way to estimate results at the earlier visits. For this reason, estimates up through week 13 are from a mixed model that only included data through week 13 and the week 15 estimates are from a separate model. Results were generated using a mixed model with repeated measures predicting change from baseline in SIB Total Score as the response variable and using baseline score, baseline MMSE strata, treatment, visit (categorical), and visit (treatment) as predictors.
  • the Placebo patients showed a decline in their LS Mean SIB scores of 1.82 (with a treatment difference of 3.59) points from Baseline to week 15 (see Table 2 and FIG. 2 ).
  • Placebo 1.94 2.63 p-value 0.1340 0.0699 80% CI for the difference ⁇ 0.31, 4.19 0.35, 4.91 Week 15* n 27 26 27 26 LS Mean (SE) ⁇ 1.82 (1.727) 1.77 (1.342) ⁇ 2.13 (1.758) 1.96 (1.255) Difference vs. Placebo 3.59 4.09 p-value 0.0503 0.0293 80% CI for the difference 0.79, 6.39 1.33, 6.85 *Results from Week 15 are from a model that included all visits.
  • BSA Body Surface Area Analysis
  • FIG. 8 shows the distribution with BSA normalization for both bryostatin dose arms for subjects with SIB Total scores at Week 5.
  • the figures for each additional follow-up visit are similar since the BSA data is unchanged.
  • the only difference between figures is that subjects who were missing SIB Total score at the specified visit were not represented in the figure for that visit.
  • Results were generated using a mixed model with repeated measures predicting change from baseline in SIB Total Score as the response variable and using baseline score, baseline MMSE strata, treatment, visit (categorical), visit*treatment, memantine use*treatment, and memantine use*treatment*visit as predictors.
  • results from week 15 were obtained from a separate model that included week 15 data for subjects who were not re-randomized.
  • Results up through week 13 were from a model that included data up through week 13 for all subjects.
  • a difference in SIB efficacy was found in patients treated with 20 ⁇ g bryostatin with or without memantine (Namenda) as background SOC therapy.
  • the 20 ⁇ g without memantine showed improvement throughout the week 13 observation period that was greater than the SIB improvement previously reported (AAIC, 2017) for the entire 20 ⁇ g group (see Table 3 and FIG. 4 below).
  • the 13-week LS Mean change in the 20 ⁇ g group without memantine was 3.83 points compared to the placebo group LS Mean change of ⁇ 1.29, with a difference of 5.11 and a p-value of 0.0437.
  • the 13-week LS Mean change in the 20 ⁇ g was 4.22 compared to the Placebo group LS Mean change of ⁇ 1.32 with a difference of 5.53 and a p-value of 0.0338.
  • the 15-week LS Mean change in the 20 ⁇ g group (mITT) without memantine was 5.88 points compared to the placebo group LS Mean change of ⁇ 0.05, with a difference of 5.93 and a p-value of 0.0576.
  • This comparison in the completer population had a difference of 6.36 and a p-value of 0.0488. Results for the completer population, therefore, were generally similar to the FAS population.
  • Memantine partially blocks the NMDA glutamate post-synaptic receptor that is well-known to be regulated by PKC phosphorylation. This regulation may explain prevention of bryostatin's therapeutic efficacy for the patients on maintenance doses of Memantine throughout this trial.
  • the ADCS-ADL efficacy was significant for the 20 ⁇ g but not the 40 ⁇ g dose ( FIG. 6 ).
  • the mITT group showed a difference from placebo of 1.4 (p ⁇ 0.104), while for the completers group (20 ⁇ g) showed a difference from placebo of 1.6 (p ⁇ 0.082).
  • the results offer a more clinically relevant interpretation—particularly the sustained nature of the SIB improvement caused the cumulative treatment benefits of bryostatin 20 ⁇ g.
  • the primary efficacy endpoint for each individual patient is the change in average of the SIB scores obtained in the 13 to 15-week time window from the baseline SIB score. If a patient is missing from the study at either the 13 week or 15-week time point, then the SIB for this time window is given as the one SIB value obtained. Since the number of patient missing at both the 13 week and 15-week time point was low, no SIB values were imputed. A total of 7 memantine patients and 3 memantine na ⁇ ve patients in the FAS sample were missing from the study at both week 13 and week 15.
  • the group difference was statistically assessed by considering the mean primary efficacy endpoint averaged over all patients with endpoint data in each treatment arm.
  • the Wilcoxon rank sum test was also performed to determine the robustness of the t-test.
  • Tables 4 and 5 below show the treatment arm means (SD) of the primary efficacy endpoint, and the corresponding two-sided p-values from both the test and Wilcoxon tests. Statistical comparisons between treatment differences in the means of the difference in baseline SIB and SIB at times 3, 9, and 13 weeks are given for comparison purposes.
  • Table 7 shows the mean (95% CI) of the slope for each treatment and memantine exposure combination for the unweighted data as well as these data weighted by the number of non-zero SIB measures.
  • the apparent bryostatin-induced persistence of SIB improvement is consistent with a long-lasting consequence of PKC epsilon-growth factor efficacy that could induce the growth and/or maturation of synaptic networks in the brain.
  • the present example describes the first multiple bryostatin dose treatment of AD patients in a double-blind, randomized, placebo-controlled phase 2 trial for 12 weeks.
  • the results described herein surprisingly and unexpectedly suggest that a dose level of 20 mcg can safely produce sustained improvements in the Severe Impairment Battery (SIB) scores of moderate to severe AD patients measured at week 13. Moreover, these improvements may be sustained up to 4 weeks after the termination of the dosing protocol at 11 weeks. This efficacy was only apparent in the absence of baseline, standard of care memantine therapy.
  • SIB Severe Impairment Battery
  • the following prophetic example provides a further assessment of the safety, tolerability and efficacy of bryostatin in the treatment of moderately severe to severe Alzheimer's disease subjects not receiving memantine treatment.
  • This randomized double-blind placebo-controlled, confirmatory study will compare bryostatin to placebo for the treatment of moderately severe to severe Alzheimer's disease in subjects not receiving memantine treatment.
  • the study may be 15 weeks in duration, including a safety and efficacy evaluation 30 days after the last dose of study drug. Subjects will receive 7 doses of drug during the study.
  • the primary efficacy endpoint will be the Severe Impairment Battery (SIB) scale score after 12 weeks of treatment (e.g., taking an average of SIB measures observed during the Week 13 to Week 15 time window).
  • SIB Severe Impairment Battery
  • Eligible subjects will be stratified based on Mini Mental State Exam (MMSE-2) scores 4-9 vs. 10-15 and will be randomized 1:1 to one of two treatment arms: 20 ⁇ g bryostatin or placebo for twelve weeks.
  • the first two doses of study drug will be a loading dose 20% higher (i.e., 24 pig) than the assigned dose and will be administered one week apart. Thereafter, the assigned dose of 20 ⁇ g will commence with the third dose and be administered every other week.
  • Drug is administered IV by continuous infusion over 45 ( ⁇ 5) minutes. Subjects are scheduled to receive seven doses over 12 weeks. Subjects who drop out prior to completing the Week 7 visit will be replaced, up to a maximum of 15 subjects.
  • Safety and tolerability may be determined through evaluations of adverse events (AE), serious adverse events (SAE), physical examination (PE), vital signs, 12-lead electrocardiogram (ECG), the Columbia Suicide Severity Rating Scale (C-SSRS), and clinical laboratory assessments.
  • AE adverse events
  • SAE serious adverse events
  • PE physical examination
  • ECG 12-lead electrocardiogram
  • C-SSRS Columbia Suicide Severity Rating Scale
  • the primary efficacy endpoint is defined as the SIB scale score obtained between 13 and 15 weeks post first dose.
  • the average SIB score at 13 and 15 weeks will be the primary efficacy end point for patients with SIB outcome measures at both time points; otherwise, either the 13-week or 15-week SIB will be considered as the primary efficacy endpoint for patients present in the study at only one of these two times.
  • the primary efficacy analysis is based on the two-sample t-statistics of the treatment group averages from the primary endpoint. A Wilcoxon test will also be performed.
  • Patients treated with bryostatin may experience a greater improvement in cognitive function as measured by the SIB from baseline to the primary efficacy endpoint after 12 weeks of treatment, as compared to patients on placebo during the same time period.
  • the test of the null hypothesis will be a superiority test based on the two-sample t-test, and only an improvement in the SIB score from baseline is of clinical significance.

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