33% 67% 33% 1 10/9/2018 Endocrine Aging Initiates Late Onset - - PDF document

10/9/2018 1

Perimenopause as a Neurologic Transition State: Emergence of Vulnerabilities to Neurodegenerative Disease

Roberta Diaz Brinton, Ph.D. Center for Innovation in Brain Science University of Arizona Health Sciences and College of Medicine 2018 North American Menopause Society San Diego, Ca October 04, 2018

Women are at Greater Lifetime Risk for Alzheimer’s Disease

33%

67% 33%

10/9/2018 2

75

Prodromal AD

51

Average Age

• f Menopause

Average Age of AD Diagnosis

Perimenopause

45

Perimenopausal Transition

Endocrine Aging Initiates Late‐Onset Alzheimer’s Risk

WHY Women?

Age Perimenopause is a Bioenergetic Transition in Brain: Potential Implications for Risk of Alzheimer’s in Later Life

Brinton et al., Nature Rev Endo 2015; Yao et al, PNAS, 2009; Ding et al., 2012; Yin et al., 2015, Neurobio Aging;

10/9/2018 3

Perimenopause is a Bioenergetic Transition in Brain: Potential Implications for Risk of Alzheimer’s in Later Life

Brinton et al., Nature Rev Endo 2015; Yao et al, PNAS, 2009; Ding et al., 2012; Yin et al., 2015, Neurobio Aging;

Perimenopause is a Bioenergetic Transition in Brain: Potential Implications for Risk of Alzheimer’s in Later Life

Brinton et al., Nature Rev Endo 2015; Yao et al, PNAS, 2009; Ding et al., 2012; Yin et al., 2015, Neurobio Aging;

10/9/2018 4

Perimenopause is a Bioenergetic Transition in Brain: Potential Implications for Risk of Alzheimer’s in Later Life

Brinton et al., Nature Rev Endo 2015; Yao et al, PNAS, 2009; Ding et al., 2012; Yin et al., 2015, Neurobio Aging;

The Brain is the Most Lipidated Organ of the Body

10/9/2018 5

H2O2 cPLA2 Arachidonic Acid Sphingomyelinase Ceramidase Thiolase TC TCA Astrocytes Neurons MCT MCT Fatty Acids Acetyl-CoA Β-oxidation Ketogenesis Ketone Bodies Ketone Bodies

Sphingomyelinase Activation

Astrocyte Neuron

Myelin Sphingomyelin Ceramide Fatty Acids Ketone Bodies Ketone Bodies Acetyl-CoA Ketolysis SCOT

Mechanism of White Matter Catabolism: Mitochondrial H2O2 activation of cPLA2‐ sphingomyelinase pathway to generate myelin derived fatty acids as a substrate for ketone body generation

Klosniski,… Brinton, EBioMedicine DOI: (10.1016/j.ebiom.2015.11.002)

Can the starving brain utilize Its own source of lipids for fuel?

Brinton et al., Nature Rev Endo 2015; Yao et al, PNAS, 2009; Ding et al., 2012; Yin et al., 2015, Neurobio Aging; Klosniski et.,al , EBioMedicine DOI: (10.1016/j.ebiom.2015.11.002)

Perimenopause is a Bioenergetic Transition in Brain: Coincident with White Matter / Myelin Disintegration

10/9/2018 6 Lipid Droplet in Brain is Coincident with Myelin Dis-Integration and Fatty Acid Metabolism

Klosniski,… Brinton, EBioMedicine ebiom.2015.11.002)

Ceramide Panel ng/mg tissue P-Value Reproductively Irregular Reproductively Incompetent Aged Irregular vs Incompetent Irregular vs Aged Incompetent vs Aged Sph 1.49 1.81 1.60 0.306 0.936 0.698 SPA 0.29 0.31 0.29 0.954 0.999 0.939 S1P 0.66 1.12 1.18 0.022 0.017 0.985 C14-cer 0.09 0.10 0.08 0.594 0.985 0.478 C16-cer 2.04 2.42 2.25 0.178 0.686 0.797 C18:1-cer 0.19 0.23 0.22 0.561 0.783 0.990 C18-cer 46.70 48.73 53.98 0.991 0.769 0.906 C20-cer 2.04 2.08 2.31 0.999 0.852 0.913 C22-cer 1.80 2.13 1.83 0.296 0.998 0.463 C24:1-cer 36.74 46.46 40.40 0.047 0.716 0.366 C24-cer 1.05 1.17 0.93 0.765 0.799 0.339 NEFA Panel pmoles/mg tissue P-Value Reproductively Irregular Reproductively Incompetent Aged Irregular vs Incompetent Irregular vs Aged Incompetent vs Aged EPA 9.29 10.87 14.18 0.852 0.147 0.458 Linolenic 0.58 0.69 0.65 0.976 0.991 0.999 DHA 52.5 70.2 98.4 0.631 0.052 0.343 Myristic 4.68 4.63 5.45 0.999 0.536 0.522 Palmitoleic 13.4 15.2 16.5 0.442 0.117 0.762 Arachidonic 236.8 275.6 374.6 0.733 0.023 0.136 Linoleic 25.2 31.4 33.1 0.184 0.098 0.955 Palmitic 334.3 388.0 433.1 0.156 0.009 0.347 Oleic 387.5 472.4 567.4 0.393 0.031 0.385 Stearic 259.5 264.3 351.8 0.999 0.329 0.403 TCA Panel nmol/mg tissue P-Value

MYELIN SPHINGOMYELIN Galactocerebrosid e Galactocerebrosid e CERAMIDE Galactose Galactose Phosphorylcholin e Phosphorylcholin e Sphingosine Sphingosine FATTY ACIDS KETONE BODIES

Increased Expression of Mitochondrial Proteins Involved in Fatty Acid Transport and Metabolism is Coincident with Increase in Brain Ketone Bodies

Reproductively Competent Reproductively Irregular Reproductively Incompetent Aged

HADHA Protein Levels Relative to VDAC and Normalized to Reproductively Competent *** ** ** B. VDAC HADHA

Reproductively Competent Reproductively Irregular Reproductively Incompetent Aged

CPT1 Protein Levels Relative to VDAC Normalized to Reproductively Competent ** ** ** A. CPT1 VDAC

Reproductively Competent Reproductively Irregular Reproductively Incompetent Aged

ABAD Protein Levels Relative to VDAC and Normalized to Reproductively Competent ** ** C. VDAC ABAD

0.002 0.004 0.006 0.008 0.01 0.012 0.014 Reproductively Competent Reproductively Irregular Reproductively Incompetent Aged Hippocampal mM β-Hydroxybutyrate Levels /ug protein

** * A.

0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09 Reproductively Competent Reproductively Irregular Reproductively Incompetent Aged Cortical mM β-Hydroxybutyrate Levels /ug protein

* ** * B.

0.002 0.004 0.006 0.008 0.01 0.012 0.014 0.016 Reproductively Competent Reproductively Irregular Reproductively Incompetent Aged Plasma mM β-Hydroxybutyrate Levels /ug protein

C. **

10/9/2018 7

Statistical parametric maps (SPMs) display 18F‐fluoro‐2‐deoxyglucose (FDG) uptake reductions in (A) asymptomatic perimenopause by age vs. men (B) symptomatic perimenopause vs men, (C) menopause vs. men. SPMs are represented on a color‐coded scale (1<z<3; where z>2 correspond to p<0.001) and displayed onto a standardized MRI. Mosconi et al., Neurology Neurology. 2017 26;89(13):1382‐1390

FDG-PET Brain Glucose in Perimenopausal / Menopausal Women Compared to Age-Matched Men

Statistical parametric maps (SPMs) display Gray Matter Volume and White Matter Volume reductions in (A) asymptomatic perimenopause by age vs. men, (B) symptomatic perimenopause vs men, and (C) menopause vs. men. SPMs are represented on different color‐coded scales (1<z<3; where z>2 correspond to p<0.001) and displayed onto a standardized MRI. Mosconi et al., Neurology. 2017 Sep 26;89(13):1382‐1390

MRI‐based Gray & White Matter Volumes in Perimenopausal / Menopausal Women Compared to Age‐Matched Men

10/9/2018 8

PiB‐PET Aβ deposition in Perimenopausal / Menopausal Women Compared to Age‐Matched Men

Statistical parametric maps (SPMs) display increased 11C‐PiB uptake in (A) asymptomatic perimenopause by age vs. men, (B) symptomatic perimenopause vs men, and (C) menopause vs. men. SPMs are represented on a color‐coded scale (1<z<3; where z>2 correspond to p<0.001) and displayed onto a standardized MRI. Mosconi et al., Neurology. 2017 26;89(13):1382‐1390

Metabolic Biomarker Strategy to Identify Women at Risk for Alzheimer’s Disease

11%

NO AD AD 11%

WHO IS AT RISK?

Rettberg et al., Neurobiol Aging. 2016;40:155‐63.

10/9/2018 9

Metabolic Phenotypes & Cognitive Function in Healthy Postmenopausal Women

Plot of Canonical Variables Identified by Cluster

Can 1 Can 2

Cluster 1 (n = 209) Healthy Metabolic Profile

• Low HOMA score
• Low glucose
• High HDL, low LDL
• Low triglycerides
• Low blood pressure

Cluster 3 (n = 102) Poor Metabolic Profile

• High HOMA score
• High glucose
• High triglycerides
• High HbA1c

Cluster 2 (n = 191) High Blood Pressure

• Higher glucose and HOMA
• Lower HDL, higher LDL
• Higher triglycerides
• High blood pressure
• 0.60
• 0.40
• 0.20

Verbal Memory

**

• 0.50
• 0.40
• 0.30
• 0.20
• 0.10

Executive Function

*

• 0.80
• 0.60
• 0.40
• 0.20

Global Cognition

*

ELITE: Hodis & Mack; NCT Identifier: 00114517: 643 postmenopausal women: R01AG024154 F31AG044997; P01AG026572

Rettberg et al., Neurobiol Aging. 2016;40:155‐63. Karim et al., Menopause, 2018

ApoE4

Phase 1b/2a: RCT Participants: 70 peri-post menopausal women Vasomotor Symptoms Subjective Cognitive Complaint Primary Outcomes: Safety Pharmacokinetics Exploratory Outcomes: Hot Flash Cognitive Function

Outcomes

 No indicators of toxicity  Predictive

pharmacokinetics.

 Effective dose / 50mg

daily

 Detection of change in

hot flash frequency feasible

 Detection of change in

cognitive function feasible

 Biomarker of

responders feasible

2006‐2013 2014 2015 2016 2017

Pre‐clinical funding Alzheimer’s Association Patents Filed

Project Timeline

Final Clinical Report

Pre‐clinical Development Proof‐of‐concept In vivo efficacy Alzheimer’s Association

Formulation Development

Formulation Pilot Samples Stabiliy / Release ikinetics GMP Manufacturing & Testing Development

Manufacturing Funding Coral Street Partners IRB Submitted IRB Approved Phase I/IIa Clinical Trial

Clinical/Regulatory

NIA Clinica Trial R01 AG 033288

Patents Prosecution

Clinicaltrials.gov NCT01723917

Estrogen Receptor  Targeted PhytoSERMs for Menopausal Symptoms: Phase 1b/2a clinical trial for Safety and Feasibility

Treatment Placebo, 50mg, 100mg 1/day for 3 months

Zhao et al., Exp Biol Med 2002 Jul;227(7):509-19. Zhao et al., Endocrinology. 2009. 150(2):770-83. Zhao et al., Menopause. 2011.10:1131-42; Hamilton et al., Brain Res. 2011, 1379:11-22; Yao et al., Brain Res. 2013,1514:128-41; Hernandez et al, Menopause. 2018 2:191-196; Schneider et al., 2018 under review

10/9/2018 10 Estrogen Receptor‐β PhytoSERMs for Menopausal Symptoms and Associated Memory Decline Estrogen Receptor‐β PhytoSERMs for Menopausal Symptoms and Associated Memory Decline Hot Flashes

Thurston, Aizenstein, Derby, Sejdić, Maki. Menopausal hot flashes and white matter

• hyperintensities. Menopause. 2016

Trails B

• Brinton. Estrogen-induced plasticity from cells to circuits:

predictions for cognitive function. Trends Pharmacol Sci. 2009.

PhytoSERM Responders: Mitochondrial Haplogroup and APOE Genotype Change in Trails-B

10/9/2018 11

Lessons from the 67% & Risk for Late Onset Alzheimer’s

67% 33%

Lessons learned: Women undergo a chronological and endocrine aging transition state characterized by:

• Decline in glucose metabolism in brain
• Reliance on alternative fuel pathway
• Risk for utilization of white matter as ketone fuel supply
• APOE4 genotype exacerbates bioenergetic crisis
• Increased prevalence of LOAD in women: they start earlier
• Transitions of female aging involve a set of sequential, system‐

level adaptions.

• Perturbing one component of the system induces adaptations in
• ther components‐ not a course correction – becomes a

different functioning system.

• The female aging brain is a dynamic adapting system with

survival back‐up mechanisms.

• Therapeutics have windows of opportunity. One type of

therapeutic will not fit all for all time.

Team

• Fei Yin, Ph.D.
• Ronald Irwin, Ph.D.
• Shuhua Chen, Ph.D.
• Jennifer Mao
• Gerson Hernandez, M.D.
• Christine Solinsky, Ph,D.
• Aarti Mishra
• Eliza Bacon
• Maunil Desai
• Yvette Wang
• Claudia Lopez
• Jamaica Rettberg, Ph.D.
• Lauren Klosinski, Ph.D.
• Tian Wang, Ph.D.

Collaborators

• Lisa Mosconi, Ph.D. Cornell University
• Regine Sitruk‐Ware, M.D. Rockefeller Population Council
• Wendy Mack, Ph.D. USC
• Lon Schneider, M.D. USC NIA ADRC
• Meng Law, M.D. USC NIA ADRC
• Arthur Toga, Ph.D. USC LONI
• Yonggang Shi, Ph.D. USC LONI
• Julie Zissimopolis, Ph.D.
• Nophar Geifman, Ph.D. Univ Manchester
• Helena Chui, M.D. USC NIA ADRC
• Michael Rogawski, M.D.UC Davis

Sponsors

• National Institute on Aging
• Alzheimer’s Drug Discovery Fd
• Alzheimer’s Association
• The Paul Slavik Trust

Brinton Research Team, Collaborators & Supporters

10/9/2018 12

Reproductively Irregular Reproductively Incompetent Aged

%of Axons in the Schaffer Collateral Pathway

Reproductively Irregular Reproductively Incompetent Aged

% of Axons in the Anterior Commissure

Reproductively Irregular Reproductively Incompetent Aged

% of Axons in the Corpus Callosum

D. E. F. ** ** * *

• A. Reproductively Irregular
• B. Reproductively Incompetent
• C. Aged

Structural Integrity of White Matter in Endocrine Aging Female Mice

2μm 2μm 2μm 5nm 5nm 5nm

Klosniski,… Brinton, EBioMedicine ebiom. 2015.11.002)

Metabolic Biomarker Strategy for Early Identification of Women at Risk for AD

Glucose HDL Glucose HDL cholest cholesterol l Hemoglo Hemoglobin A1c in A1c HOMA HOMA (ins (insulin r ulin resistance) sistance) LDL cholest DL cholesterol Sys ystolic b lic blood pr

• od pressure

essure -h

• hydroxybutyrate (k

(ketones) T Triglyce cerides Dias Diastolic blo blood pres pressure

• Gluco
• Glucose
• T

Total tal chol choles esterol

• Hemo
• Hemogl

globin A1c A1c

• Insul
• Insulin
• HDL

HDL chole cholesterol

• Syst
• Systolic
• lic blood

blood pressure pressure

• K
• Ketones

nes

• LDL chol

LDL choles esterol

• Diast

Diastolic blood pressu lic blood pressure re

• T
• Trigl

iglyceri rides

• HOMA

HOMA Score Score Rettberg et al., Neurobiol Aging. 2016 40:155‐63

10/9/2018 13

Post-menopausal aging

Upregulation of antigen presentation Increased proliferation

• f T-Lymphocytes

Increased expression of MHCI and MHCII molecules

Chronological Aging

Increased proliferation

• f T-Lymphocytes

Microglia Astrocytes

Perimenopausal transition

Downregulation of antigen presentation Infiltration of T-Lymphocytes

Blood vessel Brain Increased expression of MHC-I and MHC-II molecules Downregulation of antigen presentation Upregulation and activation of antigen presentation Activation of innate response due to Chronological aging leading to crosstalk between innate and adaptive responses Recruitment and activation of adaptive response during Perimenopausal transition

Chemotaxis of phagocytes T cell activation & proliferation T cell apoptosis downregulated T cell activation downregulated T cell activation & differention

Mirshra, Desai, Brinton

Dynamics in Immune System Transcriptome Coincident with Bioenergetic Transition During Perimenopause

PhytoSERM Responders: Mitochondrial Haplogroup and APOE Genotype Change in Trails-B

Changes in trial B time Changes in trial B time Changes in trial B time (s) Changes in trial B time (s)