WO1985003869A1 - Method of treating memory disorders of the elderly - Google Patents

Abstract

Method of treatment for memory disorders of the elderly comprising administering manganese-containing pharmaceutical preparations in appropriate ratios with isoleucine, methionine, phenylalanine, tyrosine and valine and in appropriate ratios as between the amino acids used to improve the memory of affected individuals; each of these to be given in cumulative amounts appropriate to the individual patient in a schedule of treatment which varies in amount, frequency and said ratios as it reflects the changing degrees of imbalance of the affected individual with adjustments in metabolic balance as it approaches that present when loss of memory developed its first manifestations clinically.

Description

METHOD OF TREATING MEMORY DISORDERS OF THE ELDERLY BACKGROUND OF THE INVENTION

1. Field of the invention

Loss of memory becomes a progressively commoner problem as the individual ages. It occurs in a great many degenerative brain diseases. Degenerative brain disease is frequently associated with disturbances in glucose metabolism. Such disturbances may be characterized by confusion as well as memory loss. Confused states that are associated with memory loss and also with low blood sugar levels include pellagra, Alzheimer's disease, later stages of Parkinsonism in many cases, Korsakoff's syndrome with Wemicke's in alcoholism and many less well-known syndromes. Kwashiorkor and marasmus, severe forms of protein depletion commonly lapse into stuporous and confused, states in their later stages, and postoperative protein depletion may demonstrate similar symptomatology.

The difficulties in explaining and treating these diseases may be taken to indicate how fundamental are the metabolic changes that underlies these frequently terminal neurological events.

Any attempt to understand the metabolism of glucose eventually encounters the tricarboxylic acid cycle in the mitochondrion. The factors involved in maintaining balanced production of high resonant compounds and distribution appears to be involved in each of the above syndromes. PRIOR ART STATEMENT

2. Prior Art

"Monoamine oxidase is a flavoprotein oxidase of PURPORTED CENTRAL METABOLIC IMPORTANCE CONVERTING NEUROACTIVE AMInES INTO INACTIVE ALDEHYDES....The flavin linked monoamine oxidase is localized in the OUTER MITOCHONDRIAL MEMBRANE OF ANIMAL CELLS. Walsh pp. 402 403. "Actions: Monoamine oxidase is a complex enzyme system widely distributed throughout the body. Drugs that inhibit monoamine oxidase in the laboratory are associated with a number of clinical effects. Thus it is UNKNOWN WHETHER MAO INHIBITOR PER SE, OTHER PHARMACO LOGICAL ACTIONS OR AN INTERACTION OF BOTH is responsible for the clinical effects observed. Therefore the physician should become familiar with all the effects produced by drugs of this class. PDR (Physicians' Desk Reference 1933) p. 1516.

Two classifications of amine oxidases were presented in 1959. That by Blashko, et al used the response to carbonyl inhibitors to distinguish between the activities of the various amine oxidase. That by Zeller, et al, used semicarbazide inhibitors. The use of inhibitors to classify amine oxidases reflected difficulties encountered in purifying these enzymes and studying the structure of their active sites.

"A. Occurence

"Monoamine oxidase (MAO) has been found in all classes of vertebrates so far examined (1970): mammals birds reptiles, amphibians and teleosts (161). The enzyme occurs in many different tissues particularly in glands, plain muscle, and the nervous system (162). In man the parotid and submaxillary glands seem to be the richest source of MAO (163). It also occurs in molluscs and plants (4)." Kapeller- Adler .31.

In 1957 iproniazid was introduced for the treatment of depression.

New York Times article June 4, 1981, p. B9. It has been studied extensively and is a monoamine oxidase inhibitor. However, it has a variety of effects besides the effect on depression. These have frequently posed problems.

The use of these drugs has continued to be empirical. Iproniazid was removed fromthe market becauseof severe liver toxicity. It is interesting to note that these drugs exert their beneficial effect in depressed patients anywhere from one to several weeks after treatment is begun.

''In some instances the improvement may progress to a state of euphoria, hypomania, or even mania. Central stimulatory effects are seen with these drugs in normal individuals as well as in depressed patients." Bevan.

Other effects are orthostatic hypotension, allergic reactions affecting the liver, dizziness and a number of anticholinergic type symptoms.

Disturbances in glucose level have been associated with a variety of diseases. The maintenance of the sugar within normal range is a matter of bringing the level down in hyperglycemia, and of bringing it up in various kinds of hypoglycemia. Some of the hypoglycemias are transient, others longstanding. Once developed the hyperglycemia of diabetes mellitus is usually permanent or becomes so. There are instances of hypoglycemia converting to hyperglycemia and diabetes mellitus. The latter disease is of universal distribution and a major cause of morbidity and death. CHEMICAL EFFECTS OF MONOAMINE OXIDASE

"SPECIFICITY

"The enzyme isolated from a number of sources exhibits low specificity. In general, primary, secondary, and tertiary amines, trytamine derivatives and catechol amines are oxidized (1.5). The enzyme isolated from human placenta, heaver,will only attack primary amines and with simple alkyl amines increase in chain length results in increased affinity (7)." Barman p. 180.

"Inhibition of MAO leads to a very pronounced increase in the levels of norepinephrine in the sympathetic nervous system and of the monoamines serotonin, norepinephrine, and dopamine in the monoamine-containing neurones of the CNS....Large amounts of amine now accumulate in the cytoplasm. The storage sites rapidly become filled to capacity with the transmitter. This enhanced accumulation of neuroamines within the neurones is presumed to be the basis for the antidepressant action of the MAO inhibitors. . It should be added that the presence in the urine of large amounts of unmetabolized serotonin and 3 O methylated catecholamines is characteristic of patients on MAO inhibitor antidepressants. Bevan pp. 183, 184. These urinary compounds indicate clearance of the above amines from the blood and is consistent with an increased turnover rate of increased amounts of each amine.

"The flavoprotein responsible for the oxidative deamination of the catechol amine (monoamine oxidase) is found in a wide variety of tissues and is located primarily in the outer membrane of mitochondria." Frisell p.628. CHEMICAL EFFECTS ON MONOAMINE OXIDASE

Halogenated compounds enter the body frequently from the environment. The anaesthetics halothane and methoxyflurane are cases in point. "Incubation of the volatile general anaesthetics halothane or methoxyflurane (labelled with ¹⁶Cl) with hepatic microsomes, NADPH, and oxygen is accompanied by extensive

DECHLORINATION. Similarly thyroxine and triiodothyronine undergo deiodination by hepatic microsomal enzymes (8). Bacq p. 577. "Dimino and

Hoch (1972) found a considerable enrichment of iodine in liver mitochondria of rats injected with T₄. These mitochondria were more dense than those of untreated animals and and appeared to contain iodine TIGHTLY BOUND TO THEIR INNER MEMBRANES (9).

...Direct effects of T₄ on isolated mitochondria have been known for some time, but they occur only at HlGH, UNPHYSIOLOGICAL

CONCENTRATIONS and their significance is doubtful. (9) " Lash p. 332.

"The actual biochemical mechanism of thyroid hormone action on neural, tissue is poorly understood. It is evident that a single regulatory reaction has not been found to explain the multiple effects of thyroid hormones. Although the activities of more than 100 enzymes have been shown to be affected by thyroxine administration it appears that all are not influenced to the same degree. (10). Frisell p. 608 MANGANESE METABOLISM

"The early studies of Greenberg (65) with radiomanganese indicated only 3-4% of an orally administered dose is absorbed in rats. The absorbed manganese quickly appeared in the bile and was excreted in the feces. Experiments since that time with several species including man indicate that manganese is almost totally excreted via the intestinal wall by several routes. These routes cure interdependent and combine to provide the body with an efficient homeostatic mechanism regulating the manganese levels in the tissues (16, 90,129). The relative stability of manganese concentrations in the tissues to which earlier reference was made is due to such controlred excretion rather than to regulated absorption. (27)." Underwood p. 184.

It is important to realize that each of these tissues in the intestinal tract are actually, using the same system to take in and to dispose of manganese. What is being described above is the flow of manganese into mitochondria and out again. It is a reflection of the mitochondrial pool, which is a very labile pool. Manganese is carried in the plasma bound to protein. Very little of it is cleared by the kidneys.

"Injected radiomanganese disappears rapidly from the bloodstream (23. 90). Borg and Cotzias (28) have resolved this clearance into three phases. The first and fastest of these is identical to the THE CLEARANCE RATE OF OTHER SMALL IONS. SUGGESTING THE NORMAL

TRANSCAPILLARY MOVEMENT, the second can be identified with the

ENTRANCE OF THE MANGANESE INTO THE MITOCHONDRIA OF THE TISSUES,

AND THE THIRD AND SLOWEST COMPONENT COULD INDICATE THE RATE OF

NUCLEAR ACCUMULATION OF THE ELEMENT....The kinetic patterns for blood clearance and for liver uptake of manganese are almost identical indicating that the two manganese pools BLOOD

MANGANESE AND LIVER MITOCHONDRIAL MANGANESE - RAPIDLY -ENTER

EQUILIBRIUM. A high proportion of the body manganese must therefore, bein a dynamic mobile state. Underwood p. 185. "The turnover of parenterally administered ⁵⁴Mn has been directly related to the level of stable manganese in the diet of mice over a wide range (27). A linear relationship between the rate of excretion of the tracer and the level of manganese in the diet was observed and the concentration of ⁵⁴Mn in the tissues was directly related to the level of stale manganese in the diet. THIS PROVIDES

FURTHER SUPPORT FOR THE CONTENTION THAT VARIABLE EXCRETION

RATHER THAN VARIABLE ABSORPTION REGULATES THE CONCENTRATION OF THIS

METAL IN TISSUES." Underwood p. 185,

"Little is known of the mechanism of absorption of manganese from the gastrointestinal tract, or of the means by which excess dietary calcium and phosphorus reduces manganese availabilty....

Theeffeet of variations in dietary calcium and phosphorus on the metabolism of ⁵⁴Mn in rats has been studied further by Lassiter and associates (100). These worker found that the fecal excretion of parenterally administered ⁵⁴Mn was much higher and the liver retention lower, on a 1.0% calcium diet than on a 0.64 calcium diet. It appears, therefore that calcium can influence manganese metabolism by affecting retention of absorbed manganese as well as by affecting manganese absorption. Variations in dietary phosphorus had no comparable effects on the excretion of intra peritoneally administered ⁵⁴Mn, BUT THE ABSORPTION OF ORALLY

ADMINISTERED ⁵⁴Mn WAS IMPAIRED. Underwood, p. 186.

During 1970 a rash of books drew attention to energized translocation or transport and to the changes in conformation of the membranes of the mitochondria. There were extensive correlations devised with the mitochondrial oxidative phosphorylations. By 1975 some of this was discounted by claims that many solutes crossed the mitochondrial membranes without active transport. A number of postulates evolved including proton, phosphate and other mechanisms for these transfers.

In muscle and nervous tissue there are differences of sixty millivolts or more between the inner and outer surfaces of cell membranes. A Ca/Mg pump explains a wide variety of data. There seemed initially to be good data for high resonant phosphate compounds activating the cation pumps of mitochondria. Such a pump is affected by changes in concentration of calcium and it is also modulated by magnesium. Mn goes in and out of mitochondria readily. It does so by active translocation and in the company of alkaline earth metal cations. Other metals participate but to a lesser degree. A Ca/Mg pump operatiner in tandem with Na/K ATPase pumps not only fits the cell membrane, but it also would have a place in the mitochondrial scheme of things. It has long been suggested that mitochondria represent primitive bacteria originally ingested when cells developed phagocytic functions. The effective oxidation processes of the ingested cells are cited as the cause of the symbiosis developing. The corollary of that suggestion is the need that developed to correlate flow of high resonant compounds between the original cell and the mitochondria. This theory suggests that metabolic disease might well occur at the site of such a complex metabolic adjustment between the metabolism of two different cells. This mechanism of regulation is consistent with that theory.

The added point must be made that the high efficiency ascribed to mitochondria as sources of high resonant bonds highlights the need for a central control mechanism. Such a mechanism must collate the energy production of the mitochondria with the energy metabolism of the cells, organs, and indeed the entire organism. Calcium would seem a loαical choice as the modulator of a system interactive between eukaryotic cells and mitochondria . This is consisten with the present presentation.

This mechanism or system of control has been called a mechanism of regulation. Listing the sequence of components described includes cation. ATPase pump, Mn, deiodinase, thyroid hormones, monoamine oxidase and amines. ALL ARE FOUND IN CLOSE PROXIMITY IN THE MITOCHONDRIA. FORMULATION

ADDENDUM

In order to facilitate the understanding of the use of the method in diabetes mellitus and in hypoglycemic disorders as well as those diseases in which related changes of glucose in body fluids occur, this further addition is written. The MTA (or CMTA) sequence needs to be further discussed in those conditions.

In keeping with the recommendation of Marcus in the J. of the P.O.Soc. September, 1969, Vol. 52. No. 9 on page 559, for facilitating efforts of one skilled in the art to effectively use treatments described, a review of effective amounts of substances to be given is best viewed with an understanding of the underlying chemical systems that have been altered. The mechanisms of regulation here described have inherent differences in the applicable lines of reasoning than are presently associated with the disease states discussed.

"Glutamate dehydrogenation may be underscored as a major oxidative reaction in human metabolism in which an amino group, once a part of many different amino acids, is now converted to free NH₄/NH₃, NH₄ ⁺, OR NH₃ has only two fates: (1) to be reutilized or (2) to be excreted as urea." Frisell, p. 240 (1982).

"The alpha-NH₂ group of glutamate is esnecially vulnerable to oxidative removal by the process of deamination. Particularly in the liver, there is a very active dehydrogenase that is resnonsible for the deamination of glutamate to alpha-ketoglutarate

and NH4. The enzyme is present in both the cyfcosol and the mitochndria..." Ibid. This provides for rapid glutamate breakdonw both in the cytosol and in the mitochondria. It also indicates that the control mechanism for the enzyme can operate not only in the mitochondria but also in the cytosol. This then relates the dehalogenase of the endoplasmic reticulum to the glutamate dehydrogenase in the cytosol. Similarity is obvious to the dehalogenase of the inner membrane of the mitochondria which is in close proximity to the glutamate dehydrogenase in the matrix of the mitochondria.

Since the two enzymes are isoenzymes (isozymes), the mechanism for both is inferred to be the same. The dehalogenase in each case is inhibited by manganese. As a result thyroxine concentration is greater. Increased thyroxine increases the inhibition of each glutamate dehydrogenase.

The distance from the endoplasmic reticulum to the glutamate dehydrogenase in the cytosol has a concentration gradient of T₄ and T₃. The same is true for the distance from the inner membrane to the glutamate dehydrorenase in the matrix of the mitochondria. If the distance in each case is not too great, concentrations of T₄ and T₃ reaching the sites on the glutamate dehydrogenase would be adequate to result in inhibition.

Such inhibition causes an increase in amounts of metabolites required for biochemical syntheses. THIS IS CONSISTENT WITH THE ANABOLIC FUNCTIONS OF THE THYROID HOMONES. Glutamate dehydrogenase is inhibited when thyroxine occupies the relevant receptor, presumably an allosteric site. Slowing of this enzyme results in less glutamate breaking down. This in turn slows the rate of glutamate formation secondary to transamination of amino acids. With less glutamate there is less formation of glutamine and urea as well. The unaltered amino acids remain at higher levels in the cellular amino acid pools.

While MAO inhibition by thyroxine prevents destruction of biogenic amines, glutamate dehydrogenase activity inhibition prevents destruction of amino acids. While catecholamines, for instance, are increasing cellular activity, amino acids are becoming available as building blocks for peptide chain synthesis in cells. The two groups of substances are synchronized for the greater metabolism of the cells.

This is reflected in the increase in BMR.

There is an optimal range over which these metabolites are readily synchronized. Beyond that imbalances develop. These may be either at the lower or upper activities of normal physiological function. A dog or human with thyrotoxicosis, for instance, may develop hyperglycemia of such magnitude that glucosuria occurs. The attention span can shorten until the subject's normal pattern of behavior becomes less appropriate and disorganized.

To maintain health, then, the MTA (or CMTA) sequence must operate within normal limits. Fortunately it appears that these limits usually include a wide range of normal values. "A product of glutamate, gamma aminobutyric acid (GABA) is essential for brain function, because it retards transmission of nerve impulses. GABA is produced by the loss of the number one carboxyl group of glutamate: ...It may be noted that 75 percent of the total free amino acids of brain can be accounted for by aspartate, glutamate, and their derivatives."

Frisell, p. 258 (1982).

The glutamate can be synthesized, of course, from ammonia and alpha-ketoglutarate. The enzyme from beef liver, 1.4.1.3

L-Glutamate: NAD(P) oxidoreductase (deaminating),(glutamate dehydrogenase) Barman 1969 p. 170 Vol. 1, actually functions at a structural conformation conducive to such synthesis.

It is the portal of entry throughout the phyla for ammonia entering into amino acids. This was illustrated by feeding cattle shredded newsprint and using urea as a source of nitrogen.

Rose in 1955 at the end of what is one of the most important group of papers ever to appear in the world literature, and especially during this century, reported on nitrogen requirements as follows: "Later, as the minimal human requirements were revealed, the quantities of the essentials decreased, and, in their place, glycine and urea were incorporated in the food. Both of thelatter compounds can be utilized by the growing rat for the purpose in

Question (16). No reason exists for doubting that in man they are capable of performing a like function." The structure and results of the experiments then reported convincingly sustained that thesis. However, as demonstrated, alpha-ketoglutarate is formed readily as a part of the TCA cycle by isocitrate dehydrogenase.

In fact, alpha-ketoglutarate from glutamate dehydrogenase can be thought of stoichiometrically in the above context as a return of the original product to the TCA cycle.

Lehninger, that brilliant analyzer and expositor of the mitochondrion, speaks of glutamate dehydrogenase on p. 439 (1970) as follows: "Glutamate dehydrogenase, probably because of its central role in the transfer of amino groups, is an allosteric enzyme. The beef liver enzyme has a molecular weight of 280,000 and contains a number of apparently identical subunits. The enzyme ASSOCIATED INTO URGER AGGREGATES OF PARTICLE WEIGHT 2.2 MILLION WHICH ARE ROD-SHAPED. THE EQUILIBRIUM BETWEEN THE MONOMERIC AND POLYVALENT FORMS IS SHIFTED IN ONE DIRECTION OR THE OTHER BY VARIOUS EFFECTORS. The enzyme is inhibited by the effectors ATP, GTP, NADH

AND IS ACTIVATED by ADP AND CERTAIN AMINO ACIDS. It is also influenced by the PRESENCE OF THE THYROID HORMONE THYROXINE and CERTAIN STEROID HORMONES."

In this regard, Frisell on page 240 (1982) remarks: "The thyroid hormone, thyroxine, can also influence the activity of glutamate dehydrogenase but the significance of this action is not yet established." Just before that, he had said. "With regard to its macromolecular structure, glutamate dehydrogenase consists of SIX IDENTICAL SUBUNITS. As would be surmised, this subunit character of the enzyme gives it the possibility of being subject to allosteric control. Indeed, the dehydrogenase is inhibited by NADH, ATP, and GTP, and is stimulated by ADP, GDP, and SOME AMINO ACIDS.

Barman, VOL 1 (1970) pp. 170-171 1.413 is somewhat more specific:

"With enzyme isolated from beef liver,

GTP and diethylstilbesterol stimulate the oxidation of the following monocarboxylic amino acids: alanine, leucine, isoleucine, methionine valine, norleucine, norvaline and 2-aminobutyric acid.

ADP inhibits these oxidations. However, the oxidation of glutamate is inhibited by

GTP and diethylstilbesterol but is stimulated by

ADP. These data can be explained in terms of an equilibrium between different forms of the enzyme WHICH HAVE DIFFERENT RELATIVE SUBSTRATE SPECIFICITIES and it is thought that the position of this equilibrium is influenced by modifiers." It can be seen that oxidation of the monocarboxylic amino acids occurs when the dicarboxylic amino acid glutamate is not being oxidased. The glutamate is being oxidized when the monocaroxylic amino acids are not being oxidized.

In order tounderstand the' different forms', we will use as standard nomenclature that described by Lehninger (1970) pp. 58-59. It is as follows:

"Specific terras are commonly used to refer to different aspects or levels of protein structure. The term primary structure refers to the covalent backbone of the polypeptide chain and specifically denotes the sequence of its amino acid residues. Secondary structure

polypeptide chains, particularly as they occur in fibrous proteins. The term tertiary structure refers to the manner in which the polypeptide chain is bent or folded to form compact, tightly folded structure of globular proteins (Figure 3-2). The more general term conformation is used to refer to the combined secondary and tertiary structure of the peptide chain in proteins. The term quaternary structure denotes the manner in which the individual polypeptide chains of a protein having more than one chain are arranged or clustered in space. Most larger proteins, whether fibrous or globular, contain two or more polypeptide chains, between which THERE MAT BE NO COVALENT LINKAGES (Fig. 2-2). In general, the polypeptide chains of proteins usually have between 100 to 300 amino acid units (mol wt 12,000 to 36,000). A few proteins have longer chains, such as serum albumin (about 550 residues) and myosin (about 1,800 residues), However, any protein having a molecular weight exceeding 50,000 can be suspected to have two or more chains.

"Proteins possessing more than one chain are known as oligomeric proteins; theircomponent chains are called protomers. A well-known example of an oligomeric protein is hemoglobin, which consists of four polypeptide chains, two identical alpha-chains and two identical beta-chains. Each chain has about 140 amino acids. The four chains fit together tightly to form a globular assembly OF GREAT STABILITY, despite the fact that THERE ARE NO COVALENT LINKAGES. Oligomeric proteins usually contain an even number of peptide chains. There may be anywhere from two to twelve subunit chains among the smaller oligomeric proteins to dozens or even hundreds among the larger proteins. Tobacco mosaic virus particles have over 2,000 peptide chains.

"Since oligomeric proteins contain two or more polypeptide chains, which are usually not covalently attached to each other, it may appear improper or at least ambiguous to refer to oligomeric proteins as "molecules" and to speak of their "molecular weight.

However, in most oligomeric proteins, the separate chains are so tightly associated that the complete particle usually behaves in solution like a simple molecule. Moreover, ALL THE COMPONENT

CHAINS OR SUBUNITS OF OLIGOMERIC PROTEINS ARE USUALLY NECESSARY

FOR THEIR FUNCTIONS."

To bring this further into perspective in physiological terms and enable us to match structural details with observed changes in vital functions, we had best enlarge still further upon the "subunits"." This is discussed on pp. 184-185 of Lehninger as follows:

"This mechanism for hemoglobin oxygenation is directly applicable to regulatory enzymes. The binding of the first substrate molecule to one subunit of a homotropic enzyme enhances the binding of a second substrate molecule to a second subunit because there is a conformational change in the first subunit which is transmitted mechanically or sterically to the second submit. In all cases studied to date, regulatory enzymes have been found to be rather large molecules containing subunits; presumably, the existence of interacting unitsis necessary for their function.

"Note that the term "subunit" IS AMBIGUOUS and may have Two

DIFFERENT MEANINGS WHEN APPLIED TO OLIGOMERIC PROTEINS. Hemoglobin contains four structural subunits or protomers, i.e., the two alpha and two beta chains, but two functional subunits, i.e., the two alphabeta half molecules.

ISOZYMES

"Recent research has revealed another way in which the activity of some enzymes may be controlled THROUGH FEATURES OF THEIR MOLECULAR STRUCTURE. A number of different enzymes have beer found to exist in multiple molecular forms WITHIN A SINGLE SPECIES, or EVEN WITHIN A SINGLE CELL. Such multiple forms can be detected and separated by gel electrophoresis of cell extracts; they are therefore distinct molecular species differing in net electrical charge. Multiple forms within a single species or cell are called isozymes (or isoenzymes).

"Lactate dehydrogenase, one of the first enzymes in this class to have been studied extensively, exists in five different major forms, or isozymes, in the tissues of the rat (Figure 9-12). These have been obtained in pureform. Although all five isozymes of lactate dehydrogenase catalyze the same reaction overall, they have DISTINCTLY DIFFERENT K_m VALUES for their substrates; the biological significance of these differences will be described in Chapter 15 and 18. The five isozymes all have the same particle weight, about 134,000, and all contain four polypeptide chains, each of mol wt 33,500. When glutamate dehydrogenase is inhibited, less transamination occurs. This results in less breakdown of amino acids, those which have transaminase enzymes. Although this is true of the inhibition of the polymeric form of glutamate dehydrogenase, the monomeric forms proceed to oxidatively deaminate the three branched chain amino acids.

Deamination of the methionine chain presumably occurs at the L-homoserine hydro-lyase (deaminating) conversion to 2-oxo-butyrate. This enzyme is also named homoserine dehydratase with HOH being added and NH₃ and HOH being products of the reaction, However, methionine and also 2-aminobutyrate are listed as substrates of glutamate dehydrogenase, presumably in the monomeric form. This raises some question ar to the route of degradation of methionine in its ultimate production of succinyl CoA. The cytosol is a thick suspension. The matrix of the mitochondria may be an even thicker suspension with a very high protein content. In view of the monomers of glutamate dehydrogenase occurring in such milieu, it would be consistent to think of methionine breakdown not involving the

B-6 assisted step in this context.

Lysine and threonine are the two essential amino acids not transaminated. In fact, they are not broken down readily. Lysine is used for forming organic electrolytes, the polyamines, and for the synthesis of carnitine, necessary for carnitine acyl transferase activity needed to transfer branched chain fatty acids into the mitochondria.

The overall effect of the above enzymatic steps presumably would be to increase the demand for the branched chain amino acids. Thus, the two aromatic amino acids, phenylalanine and tryptophan are spared by the inhibition of glutamate dehydrogenase. On the other hand, the initial sparing of valine, isoleucine, leucine and methionine is altered subsequently by the monomers of the enzyme oxidatively deaminating them

(?methionine). Under those circumstances the sparing effect gives way to increased breakdown and increasee need for these amino acids. For the present at least, although threonine does degrade to some extent to succinyl CoA, that amino acid does not seem to be involved in either the sparing effect of the polymeric form or the increased degradation effect of the monomeric form of the inhibited glutamate dehydrogenase.

The lysine is purely ketogenic. Its contribution to the acetyl CoA pool would seem to be unaltered under these circumstances.

Alpha-ketoglutarate is formed by isocitrate dehydrogenase in the TCA cycle. This pool is enlarged by the action of glutamate dehydrogenase. Alpha-ketoglutarate dehydrogenase promptly converts it into succinyl CoA. The succinyl CoA in turn is converted to succinic acid by succinyl CoA synthetase and a molecule of GTP is formed at the same time from GDP and P_i.

Discussing the rate-limiting citrate synthase step in the TCA cycle, Frisell has said: "The synthase reaction is accepted, herefore, as a nonequilibrium reaction and becomes a major control reaction for the cycle. It is reasonable that the rate of the synthase reaction should be sensitive to the availability of acetyl CoA. IN ADDITION, HOWEVER, AN INTERMEDIATE OF THE CYCLE ITSELF, SUCCINYL COA, can INHIBIT CITRATE SYNTHESIS BY COMPETING WITH ACTIVE ACETATE."

This suggests that the size of the pools of acetyl CoA and succinyl CoA can assume prime importance in determining the overall rate of the TCA cycle. A number of substances are degraded to succinyl CoA. These include:

1. isoleucine and valine via methylmalonyl CoA;

2. branched chain fatty acids via propionyl Coa which in turn is changed into methylmalonyl CoA;

3. methionine and tryptophan via alpha-ketoglutarate to the propionyl CoA.

The methylmalonyl CoA rearranges through the action of a mutase to form succinyl CoA. This conversion requires B-12 for the enzyme to be active. The reaction on propionyl CoA itself requires biotin.

4. pyrimidine breakdown products including those from thymine also contribute to the succinyl CoA pool.

The point has been made in detail before that the polymeric glutamate dehydrogenase feeds into this pool indirectly through the alpha-ketoglutarate (2-oxo-glutarate). When the polymeric form is inhibited, the monomeric forrs increase breakdown of the above amino acids to produce succinyl CoA as if replacing that which was lost when the polymeric form was inhibited.

SUMMARY OF THE INVENTION

The present invention provides for using a method for raising blood glucose levels in degenerative brain diseases, especially of the elderly, in which memory loss and low blood sugar levels commonly occur together. The use of hyperglycemic actions of various amino acids in conjunction with manganese in effective ratios decrease insulin release in chemical hypoglycemia and is used to restore normal levels of glucose to patients with degenerative brain disease occurring .with hypoglycemia as part of the syndrome.

The present invention differs in its relation to effective amounts given in that these amounts are constantly changing, so that there is a pattern of changing amounts and frequency of administration to affected individuals.

HOW TO USE THE METHOD

DESCRIPTION OF THE PREFERRED EMBODIMENT

The approach to theelderly patient with a memory disorder requires a clear concept of how fragile the patient is and what other diseases may be complicating the clinical picture. When the clinician is satisfied with the general workup the first effort should be to accurately define the status of the glucose metabolism.

These disorders can be found through wide areas of the clinical specturm of disease. Thus, multiple small emboli of the brain from atheromatosis of the blood vessels can produce a general loss of memory comparable to that in Alzheimerls and other diseases. Of all the syndromes that of Alzheimerls is the commonest and involves millions of patients. The downhill course usually lasts some six years on the average. Alzheimer patients have flat glucose tolerance curves that demonstrate hypoglycemia during portions of the testing. The greatest difficulty with developing a program for Alzheimer's has come from the confusion about diagnosis and the constant claims that this or that or some other treatment was effective. It is remarkable for the lack of an. effective treatment and for a great number of ineffective treatments. This confusion has probably precipitated in large measure the present clinical crisis. The false hopes have reflected an unwillingness on the part of those called upon to treat the disease to admit to their true state of knowledge regarding it.

A low blood pressure is characteristic of the disease, The diastolic pressure is uniformly low. The development of slow progressive loss of cells over the anterior and parietal areas of the brain where neurons have the highest oxygen requirement of any cells in the body is consistent with loss due to recurrent intermittent metabolic insufficiency

and this conforms well to the finding of flat glucose tolerance curves. In the memory disorders of alcoholism, it is well to recall that hypoglycemia is a common finding in many alcoholics. The syndrome will respond to vitamin therapy many times if properly sustained. However, many times the alcoholic that develops loss of mmmory is left with serious memory deficits as well.

Patients with the disease frequently go through angry,excited periods of confusion. These are perhaps best explained as due to falling glucose setting off a reactive hypoglycemia following a burst of adrenalin secretion to overcome theinitial fall in the glucose. Glucose falls, adrenalin is released, glucose rises, insulin is released again. The borderline levels are not sufficient to permit the patient to overcome the confusion when the adrenalin bursts occur in that situation as described above.

When a long term GTT of eight hours or less is used it ray be necessary to discontinue the test because of the adverse effect on the patient. In order to evaluate the status of the patient what is needed is control of the glucose level, i.e.,controlling thehypoglycemia.

This condition has the same problem. There are many treatments, for the cost part of limited effectiveness and a reliable effective treatment has not been available before. Now that the glucose level can be raised effectively the first effort should be to restore the glucose level to normal. For that to be used effectively, however, it is necessary to realize that there follows shifts in functioning of various amino acid pumps. The associated electroljje changes that develop with the restoration o'f the hypoglycermic to the euglyceinic may be responsible; the relative amounts of the amino acids being transported change, so that the ratios of aromatic amino acids to one another are altered as well as the ratios of amino acids in other groups. When the blood sugar is raised, there is a possibility that the blood pressure will increase as well. This mist be corrected for and the original blood pressure level established after the glucose level has been stabilized at the desired normal level. For this reason it is useful to raise the blood sugar in small steps, in small increments.

The intervals between such changes in levels may be a week or more.

The general condition of the patient must be considered. However, these medications are cumulative and it is most important that treatment not be carried past thedesired point. Thus, a stepwise treatment program helps to prevent such a situation arising. This also clearly highlights the need of the clinician to personally supervise the treatment program.

One way to do this is through the use of serial blood sugars before meals and giving the medication at that time when thepatient will be eating a meal. Such a meal should include high calibre protein.

Very likely the differentiation of some of these syndromes is best achieved by restoring a normal blood sugar and then reevaluating the status of the patient.

Because of the changes in function of the large neutral amino acid pump which includes many of the essential amino acids, it requires some time to evaluate where the patient's amino acid balance has come to rest as it were. The nonpolar residues of amino acids are in many instances those of the essential amino acids and this highlights the izaπense importance of these amino acids for the synthesis of the active sites of the enzymes.

Treatment should be directed at giving the patient tiny and The use of valine is essentially related to neuromuscular disorders. These express teemselves diagnostically in alterations in handwriting, which progressively deteriorates in Alzheimer's and Parkinsonism commonly. There is likely to be an associated striking calming effect with its use. The use of the valine, however, poses a number of metabooic considerations. Leucine is formed via the beta-leucine cobalamin-dependent shunt from valine and from branched chain fatty acids. The hypoglycemic effect of leucine can thus be potentiated by valine as a backup source of leucine. On the other hand, when there is no need for more leucine, this should not be a problem. It illustrates, however that it may well be best to be sure that the proper range of glucose values,, e.g.,

then larger amounts of L-isoleucine under control l ed circumstances .

The amounts can be increased for a time, but then must be reduced.

The effort must be to restore the isoleucine/leucine ratio to the normal range.

Many cases of memory disorder of the elderly are accompanied by changes in handwriting such as those noted by Chief Justice Holmes .

It is best to direct one' s efforts to the isoleucine initially and then later use L-valine in an effort to correct the disturbances that lead to the impairments of the handwriting. Always the amounts given should be small and gradually increased and then tapered off as the needs of the patient have been filled. This applies to each of the substances used.

Characteristically lower blood curves arefound in the degenerative brain diseases of the elderly. Of the diseases mentioned here , all but the atheromatous syndrome mentioned would be expect.ed to fall into the lower curves .

Even Parkinsonism may be characterized by memory loss , al.though this is apt to be misjudged because the medications employed are apt to alter the blood sugar levels somewhat .

The levels in the patient at base level are apt to he low for the glucose .

Example #1 is provided to indicate the treatment of an individual with low blood sugar values but without a memory loss problem. The patient was approaching retirement age and living an active , fully employed life . Example # 1 Patient M . V.

Clinical Status : The patient has a long history of a low, flat glucose tolerance test. Values were especially low a number of years ago. However, they were remaining in the 50 mg range and an attempt was made to change the low level towards the normal range of blood glucose values.

Treatment periods : Initially a weekend in which two days of treatment were undertaken. Then at various times the next three weeks.

Treatment period interval: Ranged from one week to two days. Objective findings:

I Blood glucose: Ranged upwards from about 50 milligrams/ 100 milliliters, (mg%) to 100 mg%.

II Blood pressure:

A Systolic pressure: ranged from 150 to 124 mg Hg (millimeters mercury pressure)

B Diastolic pressure ranged from 86 to 110 to 75 mm Hg in that order

C Pulse Pressure: ranged from ninety to 34 mm Hg

III Pulse: ranged from 70 to 76

Range of medicatoon:

Ratios: Mangenese (mg in manganese gluconate) 2 mg+ at one to ten day intervals. Isoleucine in quarter, half and whole tablet. 500 mg/tablet in time between meals to ten days. (1.6 to 6.7 mg/kg body weight)

(0.007 to 0. 27 Objective of Treatment: To bring glucose level to normal range of(100-110) to 140-150) mg%

Subjective findings: The patient was anxious and upset during part of period associated with a viral upper respiratory infection.

During this interval anxiety was prominent.

Clinical response: An episode of labile blood pressure occurred during the time involved and then drifted down to 124/75 over a two week period

The change in blood glacose level occurred easily.

The most striking observation was the level of 90 mg% still present six months later.

The patient continued throughout to feel considerably better from day to day than was his usual pattern.

Claims

I claim: 1 A method of treating memory loss in vertebrates comprising administering to the affected subject a nmemonically effective amount therefor of at least one compound of (a) comprising L-valine, D-valine, L-methionine,

D-methionine, L-isoleucine, D-isoleucine, their alpha-keto and alpha-hydroxy analogs, and the di- and tripeptides of the amino acids or the pharmaceutically acceptable acid addition salts thereof and an effective amount therefor of at least one compound of (b) comprising L-phenylalanine,

L-tyrosine, D-phenylalanine, D-tyrosine, their alpha-keto and alpha-hydroxy analogs, and the di- and tripeptides of the amino acids or the pharmaceutically acceptable acid addition salts thereof in a nmemonically effective ratio with an effective nonlethal amount therefor of

(c) a preparation consisting essentially of a manganese compound.