Drugs and the Brain

Parkinsons Disease 1

Clinical picture; genetics

2014 California Institute of Technology

 Parkinsons disease
1. Clinical description
2. Genetics
3. Pathophysiology
4. Biomarkers and non-human models
5. Heterozygote advantage: none known
6. Therapeutic approaches: a, Symptomatic relief; b. Protection

James Parkinson, apothecary surgeon

1817, An Essay on the Shaking Palsy, described "paralysis agitans",
from observations of 6 individuals during his daily walks in London

Parkinsons disease
(tremor at rest 3-5 Hz, pill-rolling,
slow movements, particularly when starting;
short, rapid steps)

but most Parkinson patients are either medicated or electrically stimulated

 Excellent dramatization of the large motor problems in a PD patient

http://www.youtube.com/watch?feature=endscreen&v=j86omOwx0Hk&NR=1x
 Dopaminergic neurons in the human brain: Saggital view

Substantia Nigra:
Dopaminergic neurons die in PD

Rodent brain section, stained for tyrosine hydroxylase: coronal view

 Symptoms appear
when most (50% -80%)
SNc neurons are lost.

Most people lose

dopaminergic neurons
throughout life; PD
patients have lost more.

Remaining dopaminergic
neurons may form
additional sprouts which
partially compensate for
the loss.

Nestler, Hyman, Malenka,

Molecular Neuropharmacology,
McGraw-Hill
Professional Publishing
 A hallmark of PD pathology:
Intracellular Lewy bodies, especially in dopaminergic neurons

(Lewy bodies also occur in other diseases, especially some dementias)

 PD patients often have additional symptoms and degeneration

Constipation. Detailed surveys show that most PD patients have constipation long
before the clinical symptoms.

Constipation does not predict PD.

Intestinal biopsies show Lewy bodies in the neurons of the intestinal wall.

Braak staging: various neurons with long axons through the brain show Lewy
bodies before dopaminergic neurons; but there are few or no symptoms.
(Braak & del Tredici, Neurology 2008)

Sleep disorders, especially in rapid eye movement sleep.

Olfactory problems (patients have anosmia).

Depression.

Dementia.
 3. Genetics. Familial Parkinsons disease provides a good review of biochemistry
(~ 10% of patients). Onset 30s to 50s (rarely earlier or later)

Chromosome Inheritance
Locus Gene or protein name
location pattern
PARK1 & 4q21q23 -synuclein AD
PARK4 (Membrane fusion in various organelles)
PARK2 6q25.2-q27 Parkin AR
E3 Ubiquitin ligase
PARK3 2p13 Unknown AD, IP
PARK5 4p14 UCH-L1 AD
ubiquitin-C-terminal hydrolase-L1
PARK6 1p35-p36 PINK1, PTEN-Induced Putative Kinase 1 AR
PARK7 1p36 DJ-1 AR
Uknown function
PARK8 12cen LRRK2 AD
leucine-rich repeat kinase 2
PARK9 1p36 ATP13A2 AD
PARK10- Various Much less is known various
PARK16

AD, autosomal dominant; AR, autosomal recessive; IP, incomplete penetrance

Drugs and the Brain

End of miniLecture

2014 California Institute of Technology

 H2
HO C NH 3+
C
H2
HO
reactive:
oxidative damage?

Drugs and the Brain

Parkinsons Disease 2

Pathophysiology; non-human models

2014 California Institute of Technology

 dopamine
Parkinsons disease: pathophysiology H2
C NH 3+
reactive: HO C
1. Most cases are unexplained. oxidative damage? H2
HO

2. Dopaminergic neurons may be selectively vulnerable because the cell body must
maintain large amounts of axoplasm and presynaptic proteins.

3. Dopaminergic neurons may be selectively vulnerable because dopamine is highly

reactive.

4. Pesticides (Wang et al, Eur J Epidemiol. 2011).

5. The frozen addict. An impurity in synthetic heroin.

Taken up by the dopamine transporter (expressed only in dopaminergic cells).
Kills cells.

6. The encephalitis lethargica pandemic (worldwide epidemic) of 1918 killed 20

million people. Some people experienced selective damage to dopaminergic
neurons. Presumably an autoimmune reaction was provoked by an still-unknown
infectious agent (virus or bacteria). (Awakenings, O. Sacks).
-synuclein has an unknown function; its an intrinsically disordered protein.
Mutant -synuclein forms fibrils.
-synuclein may be transmitted among cells, like a prion

Improper mitochondrial function may

also be one of the early events
4. Animal Models for Parkinsons Disease:
Drosophila that overexpress synuclein

1. The 4 dopaminergic neurons

die preferentially!
We dont know why.

(2. The cells show dense structures

like Lewy bodies)

3. The flies show a

movement disorder
 More Models for Parkinsons Disease

a. Toxin-treated mice, rats, and monkeys

b. Mice with altered PARK genes

c. Yeast that harbor synuclein mutations (Cooper et al, Science 2006)

c. Cultured cells from people carrying PD mutations (disease in a dish)

human embryonic stem cells (hESCs)

human induced pluripotent stem cells (iPSCs)

But there are still major technical issues in generating dopaminergic neurons
that behave like the vulnerable neurons.
Distinction between SNc and VTA?
Antibody stains for tyrosine hydroxylase and other markers are not yet
sufficient to reveal a true phenotype.
 Biomarkers for Parkinsons Disease

a. Experienced neurologist is the best judge. No effective blood test for PD,
Responsiveness to L-dopa is a good criterion.

b. Imaging: [125I]ioflupane, high-affinity dopamine transporter (DAT) ligand.

Single-photon emission computed tomography (SPECT)
May help to differentiate Parkinsonian Normal striatum
symptoms from conditions with similar
symptoms, such as essential tremor.

Effectiveness as a screening or
confirmatory test and for monitoring
disease progression or response to
therapy has not been established.

http://en.wikipedia.org/wiki/File:Datscan.JPG
 H2
HO C NH 3+
C
H2
HO
reactive:
oxidative damage?

Drugs and the Brain

End of miniLecture

2014 California Institute of Technology

 H2
HO C NH 3+
CO 2-
HO

levodopa, L-dopa

Drugs and the Brain

Parkinsons Disease 3

Therapeutic approaches: symptom relief

2014 California Institute of Technology

5. Heterozygote advantage: none known

6. Therapeutic approaches to Parkinsons disease

a. Symptomatic relief: L-dopa

 H2 enzyme: H2
HO C NH 3+ decarboxylase HO C NH 3+
C
CO 2- H2
HO HO

levodopa, L-dopa dopamine

zwitterion
permeates into brain does not enter brain
via a transporter

Used with carbidopa,

which inhibits decarboxylase.
Prevents hydrolysis in the blood and in the peripheral
nervous system.

D2 receptor agonist is often added. This seems to reduce dyskinesias (next slide).
 L-dopa remains effective only as long as sufficient dopaminergic neurons
remain to take up and secrete dopamine.

Side effects of L-dopa

Dyskinesias (bad movements, very common in people who have used

L-dopa for many years, often seen in TV appearances of medicated PD
patients).

Mechanism is unknown. Outside-in continued activation of Gi-coupled

pathways?

Visual hallucinations, other psychotic symptoms, sleep disturbances, and

confusion.

On-off phenomenon: abrupt and transient fluctuations in the severity of

parkinsonism at intervals during the day; such fluctuations are unrelated to
ongoing drug dosage.
 Other drugs for relief of PD symptoms.

Monoamine oxidase (MAO type B) inhibitors

Muscarinic antagonists may prolong the action of certain key interneurons in the striatum

Amantadine (blocks NMDA Receptors, may decrease excitotoxicity)

Mitochondrial stabilizers, such as coenzyme Q10 and creatine

Adenosine receptor antagonists (Gs coupled, A1 or A2A), mechanism uncertain

 Deep brain stimulation
for Parkinsons Disease
(not a drug)

Developed from ablation

Activate neurons?

Silence neurons?

Axons
passing through

Nestler, Hyman, Malenka,

Molecular Neuropharmacology,
McGraw-Hill
Professional Publishing
 H2
HO C NH 3+
CO 2-
HO

levodopa, L-dopa

Drugs and the Brain

End of miniLecture

2014 California Institute of Technology

 M3-M4 loop

H+ +
BiP
ER
IRE1 PERK

Drugs and the Brain

Parkinsons Disease 4

Therapeutic approaches: protection by small molecules

2014 California Institute of Technology

 Does deep brain
stimulation for
Parkinsons disease
delay degeneration?

Data are unclear,

both in humans
and animal models.

Nestler, Hyman, Malenka,

Molecular Neuropharmacology,
McGraw-Hill
Professional Publishing
 Inverse correlation between 3
a persons history of tobacco use & susceptibility to Parkinsons disease

Pools
1. Meta-analysis of 45 studies
case cohort all
2
Relative
risks

0
Hernan, 2002

individual studies: case-control cohort

2. Tanner, 2002: 33 discordant identical twins including at least one smoker. The twins
without PD smoked more than their brothers smoked (37.1 vs 25.3 pack-years, p=0.077)
 A. Tobacco use protects against PD, vs PD patients use less tobacco

B. Nicotine itself is probably a part of smokings apparent neuroprotective action

1. In rodents and monkeys, nicotine protects dopaminergic neurons against toxins

(M. Quik, several papers)
2. 4 nicotinic receptor knockout mice lack this protection
(Ryan et al, 2001)
3. Inverse correlation persists for chewing tobacco in epidemiological studies

C. We need additional human data, e. g., PD among Swedish snus users

D. Simply use nicotine patches?

1. Clinical trial under way for early-stage PD patients given nicotine patches
2. Nicotine itself is a perfect addictive drug but a sub-optimal therapeutic drug.
3. Nicotine itself activates several nicotinic receptors; many people cannot tolerate
patches
 What is the Mechanism: for Nicotines apparent neuroprotective effect?
Outside-In vs Inside-Out

Why does it matter?

Inside-out mechanisms occur at steady low concentrations of nicotine. Dosing

would be quite different for neuroprotection.
Several drug companies have active programs to discover analogs and
derivatives of nicotine, with better drug characteristics. How should one
screen for these drugs?
Using outside-in electrical assays?
Using inside-out Chaperoning assays?

An inside-out mechanism would involve many additional molecular targets, in

the endoplasmic reticulum and Golgi apparatus.

Outside-in mechanisms seem unlikely,

because elevated intracellular Ca2+ tends to kill dopaminergic neurons.

Most recent review: Lester et al., Biological Psychiatry. 2012

 Inside-out and upregulation-based mechanisms
Generate three hypotheses about the neuroprotective effects of tobacco use in PD

1. Circuit-based:
Cell-selective upregulation of 42
nicotinic receptors
(pharmacological deep brain stimulation)

2. Presynaptic:
Selective upregulation in
nerve terminals of dopaminergic neurons

3. Cell-delimited:
Pharmacological chaperoning
of intracellular receptors
reprogram cell physiology

(Miwa et al, Neuron 2011

Lester et al, Biol. Psych 2012)
 Inside-out Drug Action by Nicotine at 42 nAChRs May Suppress
Endoplasmic Reticulum Stress and a Pathological Unfolded Protein Response
nAChR
see nicotine addiction Plasma
membrane
Clathrin

Early Secretory
endosome vesicle
Golgi
Nicotine in CSF COPI ATF6

Lysosome

Golgi
complex
COPII vesicle
Sec 13/31
COPI ATF
Pharmacological 6
Chaperoning COPII
upregulation Sec24
Endoplasmic Sec23 Sar1
reticulum

IRE1 nAChR PERK

M3-M4 loop
Unfolded protein response
Do neurons survive ATF4
Despite stressors? eIF2
H+ +
XBP1 UPRE BiP
ER
IRE1 PERK
Nucleus
 M3-M4 loop

H+ +
BiP
ER
IRE1 PERK

Drugs and the Brain

End of miniLecture

2014 California Institute of Technology

 Drugs and the Brain

Parkinsons Disease 5

Therapeutic approaches: protection by proteins or gene therapy

2014 California Institute of Technology

 The limiting neurotrophic factor hypothesis for
neuronal survival
Greek, nourishment

Usually, more
neurons initially
appear in a ganglion
or nucleus than are
required to innervate
the target cells.

The excess neurons die

This occurs because

the target secretes a
limiting amount of a
trophic factor

Kandel et al.,Principles of Neural Science

McGraw-Hill Professional Publishing
 GDNF, a neurotrophic factor

Since the early 1990s, several pharmaceutical companies have experimented with pumps that
infuse glial cell derived neurotrophic factor (GDNF) in or near the substantia nigra or its target,
the striatum.

Several companies abandoned, despite anecdotal stories of success; others continue.

artemin ( a GDNF homolog)

Part of a growth factor receptor

PDB: 2GHO
 Attempts at Gene therapy for PD

Using adeno-associated viruses modified to express the protein of interest.

AAV2 is a viral vector. Lentivirus vector also show promise.

Further attempts with GDNF

Attempts with neurturin. Insufficient encouraging results

 Gene therapy with
glutamate decarboxylase
in
subthalamic nucleus
AAV2-GAD

Safety established;
effectiveness unknown.
Phase II shows initial
Encouraging results
(LeWitt et al.,
Lancet Neurol, 2011) Nestler, Hyman, Malenka,
Molecular Neuropharmacology,
McGraw-Hill
Professional Publishing
 Drugs and the Brain

End of Unit on Parkinsons Disease

2014 California Institute of Technology

 6. Therapeutic approaches to Parkinsons disease

b. Arrest the degeneration Goal: intervene in early-stage PD with drug

taken from that point.

Some degeneration has already occurred.

Good example of the interplay between diagnosis & therapy.