Acetylcholinesterase inhibitors as disease-modifying therapies for Alzheimer's disease

The therapeutic arsenal for the treatment of Alzheimer's disease (AD) remains confined to a group of four inhibitors of AChE and one NMDA receptor antagonist, which are used to provide a relief of the very late symptoms of the dementia, i.e. the cognitive and functional decline. In line with the growing body of evidence of the pivotal role of the beta-amyloid peptide (Abeta) in the pathogenesis of AD, alternative classes of drugs targeting mainly the formation or the aggregation of Abeta are actively pursued by the pharmaceutical industry, as they could positively modify the course of AD, stopping or slowing down disease progression. While the first amyloid-directed disease-modifying drugs go ahead with their clinical development and could reach the market as soon as 2009, mounting preclinical and clinical evidences is pointing towards a disease-modifying role also for currently marketed anti-Alzheimer AChE inhibitors (AChEIs), particularly for donepezil. In this review, the neuroprotective effects exhibited by currently commercialized AChEIs will be briefly discussed, together with the secondary mechanisms through which they could exert such effects. This review will focus also on particular classes of AChEIs, namely dual binding site AChEIs, which are being purposely designed to target Abeta aggregation and / or other biological targets that contribute to AD pathogenesis, thus constituting very promising disease-modifying anti-Alzheimer drug candidates.