M1 muscarinic agonists target major hallmarks of Alzheimer's disease--an update

The M1 muscarinic receptor (M1 mAChR), preserved in Alzheimer's disease (AD), is a pivotal target that links major hallmarks of AD, e.g. cholinergic deficiency, cognitive dysfunctions, beta-amyloid (Abeta) and tau pathologies. Some muscarinic agonists, while effective in AD, had limited clinical value due to adverse effects and lack of M1 selectivity. The M1 selective muscarinic agonists AF102B [Cevimeline], AF150(S) and AF267B - i) elevated alphaAPPs, decreased Abeta levels and tau hyperphosphorylation, and blocked Abeta-induced neurotoxicity, in vitro, via M1 mAChR-modulation of kinases (e.g. PKC, MAPK and GSK3beta); ii) restored cognitive deficits, cholinergic markers, and decreased tau hyperphosphorylation in relevant models with a wide safety margin. AF267B decreased brain Abeta levels in hypercholesterolemic rabbits and decreased CSF Abeta42 in rabbits and removed vascular Abeta42 deposition from cortex in cholinotoxin-treated rabbits. In 3x transgenic-AD mice that recapitulate the major pathologies and cognitive deficits of AD, chronic AF267B treatment rescued cognitive deficits and decreased Abeta42 and tau pathologies in the cortex and hippocampus (not amygdala), via M1 mAChR-activation of ADAM17/TACE and decreased BACE1 steady state levels and inhibition of GSK3beta, extending findings from above. CONCLUSIONS: A comprehensive therapy should target all AD hallmarks, regardless of the culprit(s) responsible for the disease. In this context, AF267B is the 1(st) reported low MW CNS-penetrable mono-therapy that meets this challenge. Clinical trials will determine if AF267B may become an important therapy in AD.     

Novel allosteric agonists of M1 muscarinic acetylcholine receptors induce brain region-specific responses that correspond with behavioral effects in animal models

M(1) muscarinic acetylcholine receptors (mAChRs) represent a viable target for treatment of multiple disorders of the central nervous system (CNS) including Alzheimer's disease and schizophrenia. The recent discovery of highly selective allosteric agonists of M(1) receptors has provided a major breakthrough in developing a viable approach for the discovery of novel therapeutic agents that target these receptors. Here we describe the characterization of two novel M(1) allosteric agonists, VU0357017 and VU0364572, that display profound differences in their efficacy in activating M(1) coupling to different signaling pathways including Ca(2+) and β-arrestin responses. Interestingly, the ability of these agents to differentially activate coupling of M(1) to specific signaling pathways leads to selective actions on some but not all M(1)-mediated responses in brain circuits. These novel M(1) allosteric agonists induced robust electrophysiological effects in rat hippocampal slices, but showed lower efficacy in striatum and no measureable effects on M(1)-mediated responses in medial prefrontal cortical pyramidal cells in mice. Consistent with these actions, both M(1) agonists enhanced acquisition of hippocampal-dependent cognitive function but did not reverse amphetamine-induced hyperlocomotion in rats. Together, these data reveal that M(1) allosteric agonists can differentially regulate coupling of M(1) to different signaling pathways, and this can dramatically alter the actions of these compounds on specific brain circuits important for learning and memory and psychosis.     

Allosteric modulators and selective agonists of muscarinic receptors

Allosteric modulators of ligand-receptor interactions are found for a variety of receptors (Christopoulos, 2002). Allosteric agents attach to a binding site being topographically distinct from the site for conventional (orthosteric) agonists or antagonists. In the case of the muscarinic receptor, a huge selection of structurally divergent modulators has been described for different receptor subtypes (Mohr et al., 2003). Alkane-bisammonio-type compounds carrying lateral phthalimido substituents are known to have a high affinity for the common allosteric binding site of the muscarinic acetylcholine M2 receptor (mAChR M2), which is already occupied by the orthosteric antagonist N-methylscopolamine (NMS). The resulting allosteric inhibition of the dissociation of [3H]NMS from the M2 receptors in porcine cardiac homogenates served to indicate binding of the test compounds to the allosteric site. Additionally, allosteric modulators can strongly influence equilibrium binding of the orthosteric ligand: Its binding can be reduced, left unaltered or elevated, and encoded as negative, neutral, and positive cooperativity, respectively (Christopoulos and Kenakin, 2002). The cooperativity is strongly dependent on the pair of allosteric/orthosteric ligands and on the receptor subtype.     

Impact of muscarinic agonists for successful therapy of Alzheimer's disease

The M1 muscarinic agonists AF102B, AF150(S) & AF267B--i) restored cognitive impairments in several animal models for AD with an excellent safety margin; ii) elevated alpha-APPs levels; iii) attenuated vicious cycles induced by A beta, and inhibited A beta- and oxidative stress-induced apoptosis; and iv) decreased tau hyperphosphorylation. AF150(S) and AF267B were more effectve than rivastigmine and nicotine in restoring memory impairments in mice with small hippocampi. In apolipoprotein E-knockout mice, AF150(S) restored cognitive impairments and cholinergic hypofunction and decreased tau hyperphosphorylation. In aged microcebes, AF150(S) restored cognitive and behavioral impairments and decreased tau hyperphosphorylation, paired helical filaments and astrogliosis. In rabbits, AF267B & AF150(S) decreased CSF A beta(1-42 & 1-40), while AF102B reduced A beta(1-40). Finally AF102B decreased CSF A beta(total) in AD patients. Taken together, M1 agonists may represent a unique therapy in AD due to their beneficial effects on three major hallmarks of AD--cholinergic hypofunction, A beta and tau protein hyperphosphorylation.     

AF150(S) and AF267B: M1 muscarinic agonists as innovative therapies for Alzheimer's disease

The M1 muscarinic agonists AF102B (Cevimeline, EVOXACTM: prescribed in USA and Japan for Sjogren's Syndrome), AF150(S) and AF267B--1) are neurotrophic and synergistic with neurotrophins such as nerve growth factor and epidermal growth factor; 2) elevate the non-amyloidogenic amyloid precursor protein (alpha-APPs) in vitro and decrease beta-amyloid (A beta) levels in vitro and in vivo; and 3) inhibit A beta- and oxidative-stress-induced cell death and apoptosis in PC12 cells transfected with the M1 muscarinic receptor. These effects can be combined with the beneficial effects of these compounds on some other major hallmarks of Alzheimer's disease (AD) (e.g. tau hyperphosphorylation and paired helical filaments [PHF]; and loss of cholinergic function conducive to cognitive impairments.) These drugs restored cognitive impairments in several animal models for AD, mimicking different aspects of AD, with a high safety margin (e.g. AF150[S] >1500 and AF267B >4500). Notably, these compounds show a high bioavailability and a remarkable preference for the brain vs. plasma following p.o. administration. In mice with small hippocampi, unlike rivastigmine and nicotine, AF150(S) and AF267B restored cognitive impairments also on escape latency in a Morris water maze paradigm in reversal learning. Furthermore, in aged and cognitively impaired microcebes (a natural animal model that mimics AD pathology and cognitive impairments), prolonged treatment with AF150(S) restored cognitive and behavioral impairments and decreased tau hyperphosphorylation, PHF and astrogliosis. Our M1 agonists, alone or in polypharmacy, may present a unique therapy in AD due to their beneficial effects on major hallmarks of AD.     

Effect of specific M1, M2 muscarinic receptor agonists on REM sleep generation

Specific agonists for muscarinic receptor subtypes were infused by microinjection into the medial pontine reticular formation of freely moving cats. The M2 agonists Oxotremorine-M and Cisdioxolane significantly increased REM sleep percentage. The results obtained with microinfusions of carbachol, a mixed muscarinic agonist, were similar to that obtained by the M2 agonists. The M1 agonist McN-A-343 did not elicit any change in sleep or REM sleep percentage. The generation of REM sleep by cholinergic stimulation of the medial pontine reticular formation may be mediated by the M2 muscarinic receptor subtype.     

Towards a high-affinity allosteric enhancer at muscarinic M1 receptors

Loss of forebrain acetylcholine (ACh) is an early neurochemical lesion in Alzheimer’s Disease (AD), and muscarinic receptors for ACh are involved in memory and cognition, so a muscarinic agonist could provide ‘replacement therapy’ in this disease. Muscarinic receptors, which couple to G-proteins, occur throughout the CNS, and in the periphery they mediate the responses of the parasympathetic nervous system, so selectivity is crucial. The five subtypes of muscarinic receptor, M₁–M₅, have a distinct regional distribution, with M₂ and M₃ mediating most of the peripheral effects, M₂ predominating in hindbrain areas, and M₁ predominating in the cortex and hippocampus—the brain regions most associated with memory and cognition, which has lead to a search for a truly M₁-selective muscarinic agonist. That search has so far been unsuccessful, but acetylcholinesterase inhibitors such as donepezil (Aricept), which potentiate cholinergic neurotransmission, have a therapeutic role in the management of AD; so the M₁ receptor remains a therapeutic target. Our approach is to develop allosteric enhancers—compounds which bind to the receptor at an ‘allosteric’ site which is distinct from the ‘primary’ site to which the endogenous ligand binds, and which enhance the affinity (or efficacy) of the endogenous ligand. We have developed radioligand binding assays and analyses for the detection and quantitatitation of allosteric interactions of a test agent with labelled and unlabelled ‘primary’ ligands, and we report here some results of the initial phase of a chemical synthesis project to develop potent and selective allosteric enhancers at muscarinic M₁ receptors.     

The utility of muscarinic agonists in the treatment of Alzheimer's disease

Alzheimer’s disease is a progressive neurological disorder characterized by amyloid plaques and neurofibrillary tangles along with memory and cognitive deficits associated with a loss of basal forebrain cholinergic neurons. Efforts to treat Alzheimer’s disease have focused on compounds that elevate cholinergic activity such as cholinesterase inhibitors and direct acting muscarinic and nicotinic agonists. Low efficacy and poor selectivity of available compounds have limited the clinical utility of muscarinic agonists. Recent studies suggesting a role for muscarinic agonists in regulating the production of Aβ raise the possibility that selective M₁ agonists could be useful in treating not only the symptoms, but also the underlying cause(s) of Alzheimer’s disease. Thus, renewed efforts have focused on the development of compounds with improved selectivity for M₁ receptors and lower toxicity. 5-(3-ethyl-1,2,4-oxadiazol-5-yl)-1,4,5,6-tetrahydropyrimidine (CDD-0102) is a potent M₁ agonist with a low side effect profile that enhances memory function in animal models of Alzheimer’s disease. The available preclinical data suggest that CDD-0102 may be useful in the treatment of Alzheimer’s disease.     

M2 muscarinic receptors mediate pressor responses to cholinergic agonists in the ventrolateral medullary pressor area

Microinjections of cholinergic agonists into the ventrolateral medullary pressor area (VLPA) evoke increase in blood pressure (BP) and heart rate (HR). Recently two major subtypes of muscarinic receptors (M1 and M2) have been identified. This investigation was designed to study the role of these muscarinic receptor subtypes in pressor responses of cholinergic agonists in the VLPA. Male Wistar rats were anesthetized with pentobarbital or decerebrated at mid-collicular level. The rats were artificially ventilated and BP and HR were recorded. Ventral medulla was exposed and the VLPA identified bilaterally by microinjections of L-glutamate. Microinjections of cis-methyldioxolane (CD, a specific agonist of M2 receptors) in the doses of 0.004-4 nanomol (nmol)/site into the VLPA evoked an increase in BP (13-56 mm Hg) and HR (7-24 bpm) which lasted for 10-50 min. Intravenous injections of the same doses of this agent failed to evoke a response. AFDX-116 (a specific M2 muscarinic receptor antagonist) microinjected into the VLPA (0.2-1.6 nmol-/site) evoked depressor responses (6-20 mm Hg). Microinjections of this agent into the VLPA prevented the pressor responses to subsequent microinjections of CD at the same sites, indicating that AFDX-116 blocked M2 receptors. AFDX-116 rendered neurons in the VLPA unresponsive to L-glutamate but this effect lasted for 30-40 min while the hypotensive and M2 receptor blocking effect lasted for 60-150 min. McN-A343 (a specific agonist for M1 receptors) or pirenzepine (PZ, a specific antagonist of M1 receptors) injected into the VLPA (0.4-4 nmol/site) failed to evoke any response.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sphingomyelinase selectively reduces M1 muscarinic receptors in rat hippocampal membranes

Although there is evidence that nicotinic acetylcholine (Ach) receptors are influenced by ceramides, we do not currently know whether or not these sphingolipids can also regulate the muscarinic subtypes of Ach receptors. Using the whole-cell patch technique, we demonstrated that the effectiveness of the muscarinic receptor agonist pilocarpine, in enhancing spontaneous inhibitory postsynaptic currents in CA1 pyramidal cells, was completely abolished in hippocampal slices pre-exposed to the ceramide-generating enzyme sphingomyelinase (SMase). Western blot experiments, performed with biotinylated hippocampal membranes, showed that this electrophysiological defect possibly relies on the loss of M1 muscarinic Ach receptors at the cell surface. However, the effect appears to be relatively specific as the cell-surface expression of M4 muscarinic receptors was not found to be impacted by SMase treatment. Interestingly, we observed that G protein-coupled receptor kinases 2 and β-arrestin1/2 interactions with M1-immunoprecipitated proteins were substantially augmented in SMase-treated slices and that the reduction of cell-surface M1 muscarinic receptor expression generated was completely suppressed by the muscarinic antagonist atropine. Collectively, our data suggest that selective internalization of M1 muscarinic receptors can be accentuated in neurons subjected to high ceramide levels. The potential physiopathological implications of this finding are presented.     

Disinhibition in the rat septum mediated by M1 muscarinic receptors

Acetylcholine (ACh) has been documented as an important central neurotransmitter. We have investigated the actions of ACh within the dorsolateral septal nucleus of the rat to examine its actions within this nucleus, specifically how it may interact to modulate the inhibitory action of gamma-aminobutyric acid (GABA), the known inhibitory transmitter in this area. Our results demonstrate that ACh, acting on M1 muscarinic receptors leads to disinhibition by decreasing GABA release.     

Progress toward a high-affinity allosteric enhancer at muscarinic M1 receptors

Loss of forebrain acetylcholine is an early neurochemical lesion in Alzheimer's disease (AD). As muscarinic acetylcholine receptors are involved in memory and cognition, a muscarinic agonist could therefore provide a "replacement therapy" in this disease. However, muscarinic receptors occur throughout the CNS and the periphery. A selective locus of action of a muscarinic agonist is therefore crucial in order to avoid intolerable side effects. The five subtypes of muscarinic receptors, M1-M5, have distinct regional distributions with M2 and M3 receptors mediating most of the peripheral effects. M1 receptors are the major receptor subtype in the cortex and hippocampus-the two brain regions most associated with memory and cognition. This localization has led to a, so far unsuccessful, search for a truly M1-selective muscarinic agonist. However, acetylcholinesterase inhibitors, such as donepezil (Aricept), which potentiate cholinergic neurotransmission, do have a therapeutic role in the management of AD and so the M1 receptor remains a viable therapeutic target. Our approach is to develop muscarinic allosteric enhancers-compounds that bind to the receptor at an "allosteric" site, which is distinct from the "primary" site to which ACh binds, and which enhance ACh affinity (or efficacy). Having discovered that a commercially available compound, WIN 62577, is an allosteric enhancer with micromolar potency at M3 receptors, we report here some results of a chemical synthesis project to develop this hit. Modification of WIN 62577 has led to compounds with over 1000-fold increased affinity but, so far, none of these extremely potent compounds are allosteric enhancers.     

M1 and M3 muscarinic receptors: specific roles in sleep regulation.

P-fluoro-hexahydro-sila-difenidol hydrochloride (p-F-HHSiD) (15, 30 micrograms) and pirenzepine (7.5, 15, 30 micrograms), which are highly selective M3 and M1 muscarinic antagonists, respectively, were injected intracerebroventricularly into freely moving rats. p-F-HHSiD (30 micrograms) reduced wakefulness (W) (from 34.7 +/- 3.1 to 24.9 +/- 1.3 min) and increased slow wave sleep (SWS) (from 56.7 +/- 2.4 to 67.2 +/- 1.5 min); however, it did not modify desynchronized sleep (DS) latency and percentage in 6 h recordings. W and SWS were not affected by pirenzepine (7.5, 15, 30 micrograms) which decreased significantly DS amount but left unaffected DS latency. The results suggest that each muscarinic receptor subtype may induce different and specific changes in sleep phases and cortical desynchronization processes.     

Association analysis for the muscarinic M1 receptor genetic polymorphisms and Alzheimer's disease

In the ongoing search to reveal the pathophysiology of Alzheimer's disease (AD), the cholinergic system is important due to its role in cognitive function and its significance with respect to the results of postmortem pathology and animal model studies. For this investigation, we tested the hypothesis that the allelic variant (C267A) of the cholinergic receptor muscarinic 1 (CHRM1) confers susceptibility to AD or is related to its age of onset, in a sample population of 232 AD patients and 169 normal controls. The distribution of the CHRM1 genotypes (p = 0.919) and alleles (p = 0.327) did not differ significantly comparing AD patients and controls, even after stratification according to apolipoprotein E genotype. The onset age was not significantly different comparing the CHRM1 genotype groups. Our negative findings suggest that it is unlikely that the CHRM1 C267A polymorphism plays a substantial role in conferring susceptibility to AD. We propose that other genetic variations of CHRM1, relating either to AD or to the therapeutic response for AD, may need further investigation.     

Ontogeny of muscarinic receptors in rat brain

The ontogeny of muscarinic acetylcholine receptors in the rat brain has been examined using the radioligards, [³H]N-methylscopolamine, [³H]propylbenzilylcholine and [³H]oxotremorine-M. In the 3 regions of the brain selected for study, the cerebral cortex, the diencephalon and the medulla-pons, the receptors develop at different rates. The most rapid development takes place in the medulla with considerably slower maturation in the diencephalon and cerebral cortex. In the cortex, the agonist binding properties of the muscarinic receptors vary during development. There appears to be a 6–7 day lag in the appearance of high affinity sites following formation of low affinity sites.     

Reduction of cerebrospinal fluid amyloid beta after systemic administration of M1 muscarinic agonists.

Overproduction of the peptide amyloid beta (A beta) is a critical event in Alzheimer's disease (AD). Systemic administration of 3 M1-selective muscarinic agonists, AF102B, AF150S and AF267B, decreased cerebrospinal fluid (CSF) A beta concentrations; levels of CSF secreted beta-APP were not significantly altered. Rabbits treated for 5 days with s.c. injections of each drug (2 mg/kg/day) had levels of CSF A beta which were between 55 and 71% of control for A beta 1-40 and between 59 and 84% of control for A beta 1--42.     

Loss of high-affinity agonist binding to M1 muscarinic receptors in Alzheimer's disease: implications for the failure of cholinergic replacement therapies

Cholinergic replacement therapies have yielded little or no clinical improvement in Alzheimer's disease (AD). Since the number of postsynaptic muscarinic receptors remains unchanged in the cerebral cortex, the involvement of other neurotransmitter systems may account for this limited efficacy. Alternatively, there may be a defective coupling of the muscarinic receptor with its nucleotide-binding protein in AD, which would severely limit the ability of cholinergic agonists to activate intracortical second messengers. To address this possibility, we assessed the ability of the putative M1 muscarinic receptor to form high-affinity agonist-receptor complexes with guanine nucleotide regulatory proteins in postmortem frontal cortex. Agonist affinity states of the M1 muscarinic receptor were measured by carbachol/[3H]-pirenzepine competition. M1 muscarinic receptors exhibited both high (KH) and low (KL) affinities for the agonist carbachol. High-affinity agonist binding to M1 receptors in postmortem frontal cortex samples from subjects with AD was reduced, demonstrated by an increase in the KH value. Low-affinity agonist binding (KL value) was unchanged in AD and was not significantly different from the KL value for the uncoupled receptor determined in the presence of guanine nucleotides. The increase in the KH value resulted in a 70% decrease in the average KL/KH ratio for AD as compared to control samples. Choline acetyltransferase activities correlated significantly with the KL/KH ratios (r = 0.73, p less than 0.001). These data suggest that the KL/KH ratio for muscarinic agonists may serve as a neurochemical marker of disease severity. The reduced ability of the M1 receptor subtype to form a high-affinity agonist state in AD may account for the failure of cholinergic replacement therapies to improve specific features of memory and cognition.     

Autoradiographic distribution of M1, M2, M3, and M4 muscarinic receptor subtypes in Alzheimer's disease

We studied the autoradiographic densities of all pharmacologically characterised muscarinic receptors (MR) in frontal, temporal, and visual cortex, hippocampal formation, and striatum in autopsied brains from 19 histopathologically verified patients of Alzheimer's disease (AD) and in matched controls. Almost all (16 of 19) of the AD cases were severe. In AD brains, total MR, M1, and M3 MR subtypes were found to be significantly decreased in entorhinal cortex and in most hippocampal strata. Total MR and M1 receptors were also significantly reduced in visual area and in frontal cortex of AD brains, respectively. M2 receptors were significantly reduced over hippocampal formation but increased significantly in striatum of AD brains as compared with controls. M3 receptors in AD were in the range of controls in neocortex and striatum, whereas the M4 receptor subtype was also preserved in all brain regions in AD brains when compared with controls. This is the first autoradiographic study analysing the distribution of all MR subtypes in AD brains. These changes in MR densities concur with the general pattern of neuronal degeneration occurring in AD brains and partly explain the poor response of AD cognitive decline to present cholinergic supplementation therapies. Although M3 and M4 MR were labelled with nonselective approaches, the preservation of M4 and to a lesser degree M3 MR subtypes in AD brains could open an alternative way for the symptomatic therapy of AD dementia. Synapse 26:341–350, 1997. © 1997 Wiley-Liss Inc.     

Autoradiographic localization of peripheral M1 muscarinic receptors using [H]pirenzepine

A novel antimuscarinic agent, pirenzepine, has been proposed to distinguish at least two subtypes of muscarinic receptor. M1 receptors have been designated as those displaying a high affinity for pirenzepine. Both functional and binding studies have revealed a prevalence of M1 receptors in sympathetic ganglia while autonomic effector tissues have only low densities of M1 receptors. In the present study, in vitro autoradiographic procedures have been used to localize specifically high affinity binding sites for pirenzepine (M1 receptors) in sections of guinea-pig ileum, rat superior cervical ganglion and rat submaxillary gland. The overall localization of muscarinic receptors was also studied using the non-selective antagonist, [³H]N-methylscopolamine. The highest densities of M1 receptors were found in superior cervical ganglion, sympathetic nerve bundles, myenteric ganglia and mucous secreting cells of the submaxillary gland, while lower densities were found in smooth muscle and serous secreting cells of the submaxillary gland. No area found to possess muscarinic receptors was devoid of M1 receptors.     

Cholinergic activity modulates the survival of retinal ganglion cells in culture: the role of M1 muscarinic receptors.

The control of natural cell death is mediated by neurotrophins released by target, afferent and glial cells. In the present work we show that treatment of retinal cells 'in vitro' for 48 h with 25 microM carbamylcholine induced a two-fold increase in retinal ganglion cells survival. This effect was dose-dependent and mediated by M1 receptors since it could be blocked by 1 microM telenzepine (a M1 receptor antagonist) and mimicked by 200 microM oxotremorine (a M1 receptor agonist). The effect of carbamylcholine was abolished by 10 microM BAPTA-AM (an intracellular Ca2+ chelator), 30 microM dantrolene (an inhibitor of ryanodinic receptors), 500 nM H-89 (an inhibitor of PKA), 1.25 microM chelerythrine chloride (an inhibitor of PKC) and 50 microM PD-98059 (a MEK inhibitor). Treatment with 10 microM genistein (an inhibitor of tyrosine kinase), 25 microM LY-294002 (a PI-3 kinase blocker), 30 nM brefeldin-A (a blocker of polypeptides release), 50 nM K-252a (a Trk receptor inhibitor) and 20 microM fluorodeoxyuridine (an inhibitor of cell proliferation) totally inhibited the effect of carbamylcholine. Taken together our results indicate that muscarinic activity controls the survival of retinal ganglion cells through a mechanism involving the release of polypeptides and activation of Irk receptors.