AU2005201819B2 - Abeta 42 lowering agents - Google Patents

Description

Regulation 3.2 Revised 2/98

AUSTRALIA

Patents Act, 1990

ORIGINAL

COMPLETE SPECIFICATION 00 TO BE COMPLETED BY THE APPLICANT NAME OF APPLICANTS: ACTUAL INVENTORS: ADDRESS FOR SERVICE: INVENTION TITLE: DETAILS OF ASSOCIATED APPLICATION NO: The Regents of the University of California and Mayo Foundation for Medical Education and Research Edward Hao Mang Koo Todd Eliot Golde Douglas Roger Galasko Sascha Weggen Peter Maxwell Associates Level 6 Pitt Street SYDNEY NSW 2000 ABETA 42 LOWERING AGENTS Divisional of Australian Patent Application No. 2001 257 022 filed on 12 April 2001 The following statement is a full description of this invention including the best method of performing it known to us:m:\docs\20011286\077040.doc I I- 00 0 1. Technical Field c The invention relates to the use of Ap 42 lowering agents to prevent, delay, or reverse the progression of Alzheimer's disease. The invention also relates to methods and materials involved in identifying Ap 42 lowering agents that can be used to prevent, delay, or reverse Alzheimer's disease as well as methods and materials involved in identifying agents that increase the risk of developing or hasten the progression of Alzheimer's disease in a mammal.

2. Background Information Alzheimer's disease (AD) is the most common form of age-related neurodegenerative illness. The defining pathological hallmarks of AD are the presence of neurofibrillary tangles and senile plaques in the brain. Amyloid P polypeptides (Ap) are the major constituents of amyloid plaques and are derived from altered processing of amyloid precursor proteins (APPs). Ap consists predominantly of two forms, Ap 40 and

AP

42 Although Ap 40 is the predominant form, recent evidence suggests that Ap 42 is the pathogenic form. In addition to A3 40 and Ap 42 the processing of APP generates other AP forms such as AP 39 AP3 3 Ap3 7 and AP 34 Genetic predisposition is the largest cause of AD in the population, accounting for perhaps 50% or more cases of this disorder (Blacker et al. (1998) Arch Neurol 55:294-6).

In the past decade, epidemiological evidence suggests that non-steroidal antiinflammatory drug (NSAID) treatment, estrogen replacement therapy, and antioxidant therapy may have beneficial effects in AD. Experimental support for these treatment \ctmethods, however, is indirect. In addlition, there is no convincing evidence from 0 randomized clinical trials that any medication tested to date slows the progression of AD.

The rational development of compounds that influence key pathways or targets involved in the development of Al) is critically important.

SUMMARY

The invention relates to the use of AP 42 lowering agents to prevent, delay, or 00 reverse the progression of AD. The invention is based on the discovery that some but not all NSAflDs useful for treating AD are those that can selectively reduce the level of the pathogenic AP42 form, do not affect the level of Aj3 4 o, and increase levels of AP3 forms smaller than Aj3 4 0 such as AI3 3 s. More specifically, the invention provides methods and materials related to identifyintg AJ3 42 lowering agents, including NSAIDs, NSAfl) derivatives, and NSAID analogues, that can reduce the level of A13 42 by reducing APP processing into Af3 42 or by increasing Af3 42 catabolism; increase the level of Af3 38 by increasing APP processing into AP 3 8; and have increased selectivity for reduction of Aj1 42 relative to inhibition of COX-l, COX-2, or both COX-1 and COX-2. In addition, the invention provides methods and materials related to identifying agents that can increase the risk of developing AD, or hasten the progression of AD, in a mammal. The invention also provides compositions and its that can be used to prevent, delay, or reverse the progression of AD.

I one embodiment, the invention provides a method of preventing, delaying, or reversing the progression of AD by administering an AP 42 lowering agent to a mammal under conditions in which levels of AP 42 are reduced, levels of APM 3 are increased, and levels of AP 4 0 are unchanged. The A0 42 lowering agent also can increase the levels of one or more of AP3 34 A(3 36 A0 37 and Aj3 39 The A13 42 lowering agent can be an NSAID, an NSAIID derivative, an NSAID analogue, or any compound that reduces levels of A03 42 increases levels of A0 3 8, and has no effects on levels of AP 4 0, levels of AP~O are neither increased nor decreased). The

AP

42 lowering agent can be an aryl propionic acid derivative, an aryl acetic acid derivative, or an amino carboxylic acid derivative. More specifically, the AP 42 lowering agent can be a structural derivative of an NSAJD such as flufenic acid, meclofenamic l acid, fenoprofen, carprofen, ibuprofen, ketoprofen, and flurbiprofen. The Ap 42 lowering 0 agent also can be a structural derivative of 5-nitro-2-(3-phenylpropylamino) benzoic Sacid). Typically, the Ap 42 lowering agent either lacks COX-1, COX-2, or both COX- 1 and COX-2 inhibiting activity, or has a greater potency for lowering Ap 42 levels C 5 than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity.

AP

42 lowering agents of the invention can be used to treat AD in a mammal such Sas a human. The mammal may not be diagnosed with AD, or may not have a genetic 00 Spredisposition for AD.

In another embodiment, the invention provides a method for developing an Ap 42 S 10 lowering agent. The method involves generating derivatives of the NSAIDs C meclofenamic acid or flufenamic acid by altering the position of the carboxylic acid group on the phenyl ring or altering the position or type of substituents on the phenyl ring opposite the carboxylic acid group. Derivatives also can be generated by altering the bond connecting the two phenyl rings, altering the carboxylic acid group to propionic acid or another substituent, or performing any combination of these alterations. The derivative is then tested to determine its ability to decrease Ap 42 levels while increasing A3 3 levels.

In another embodiment, the invention provides a method for developing an Ap 42 lowering agent. The method involves generating derivatives of the NSAIDs fenoprofen, flurbiprofen, or carprofen. Derivatives can be generated by altering the position of the propionic acid group on the phenyl ring, or altering the position or type of substituents on the phenyl ring opposite the propionic acid group. Derivatives also can be generated by altering the bond connecting the two phenyl rings, altering the acetic acid group to carboxylic acid or another substituent, or performing any combination of these alterations. The derivative is then tested to determine its ability to decrease Ap 42 levels while increasing AP38 levels.

In another embodiment, the invention provides a method for developing an Ap 42 lowering agent. The method involves generating derivatives of indomethacin by altering the carboxylic acid group to another substituent, altering the indole nitrogen to another substituent, or performing any combination of these alterations. The derivative is then tested to determine its ability to decrease Ap 42 levels while increasing Ap 38 levels.

In another embodiment, the invention provides a method for developing an Ap42 lowering agent. The method involves generating derivatives of sulindac sulfide by altering the methylthiol group, the propionic acid group, or the fluoride moiety to another Ssubstituent, or performing any combination of these alterations. The derivative is then Stested to determine its ability to decrease Ap 42 levels while increasing A3s 8 levels.

In another embodiment, the invention provides a method for identifying an Ap42 lowering agent useful for preventing, delaying, or reversing the progression of Alzheimer's. disease. The method involves treating a biological composition that has APP and an APP processing activity with a candidate Ap 42 lowering agent under 0 conditions in which APP processing occurs. An A 42 lowering agent, useful for preventing, delaying, or reversing the progression of Alzheimer's disease, is one that, when present, decreases the level of Ap 42 in the biological composition.

c In another embodiment, the invention provides a method for identifying an Ap42 lowering agent useful for preventing, delaying, or reversing the progression of Alzheimer's disease. The method involves treating a biological composition that has

AP

42 and an Ap 42 catabolic activity with a candidate Ap 42 lowering agent under conditions in which Ap 42 catabolism occurs. An Ap 42 lowering agent, useful for preventing, delaying, or reversing the progression of Alzheimer's disease, is one that, when present, decreases the level of Ap 42 in a biological composition.

In another embodiment, the invention provides a method for identifying an Ap42 lowering agent that has a greater potency for lowering Ap 42 levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity. The method involves identifying

AP

42 lowering agents by screening for those having the ability to lower the level of Ap 42 in a biological composition. The IC50 of the Ap 42 lowering agent for Ap 42 lowering can be determined by performing dose response studies. The Ap 42 lowering agent is examined for the ability to inhibit COX-1, COX-2, or both COX-1 and COX-2 using in vitro COX-1 and COX-2 inactivation assays. The IC50 for Ap 42 lowering is compared to the IC50 for COX-1, COX-2, or both COX-1 and COX-2 inhibition. An Ap 42 lowering agent that has an greater potency for lowering A3 42 levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity is one that has an IC50 for A 42 lowering greater than ten-fold the IC50 for COX-1, COX-2, or both COX-1 and COX-2 inhibition.

The greater potency for lowering Ap 42 levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity can be confirmed by demonstrating that administration of the Aj3 42 lowering agent to an animal reduces Af3 42 levels at doses that do not inhibit or only c-I minially inhibit CQX-1, COX-2, or both COX- and COX-2 activity such that significant COX-related side-effects do not occur.

In another embodiment the invention provides a method for identifying; an agent CI 5 that increases the risk of developing, or hastens progression of, AD in a patient. The method involves exposing a biological composition that has APP and an APP processing activity to a candidate agent under conditions in which APP processing occurs. The level 00 of AP 42 in the biological composition exposed to the candidate agent is compared to the N level of AD 42 in a biological composition not exposed to the candidate agent. The candidate agent is one that can increase the risk of developing, or hasten the progression N- of, AD if an increase in the level of AIP 42 in the biological composition exposed to the agent is observed when compared with the level of A13 42 in the biological composition not exposed to the agent.

In another embodiment, the invention provides a method for identifying an agent that increases the risk of developing, or hastens progression of; AD in a patient The method involves exposing a biological composition that has Aj3 42 and an Aj3 42 catabolic activity to a candidate agent under conditions in which AP 42 catabolism occurs. The level of A1 42 in the biological composition exposed to the candidate agent is compared to the level of AP 42 in a biological composition not exposed to the candidate agent The candidate agent is one that can increase the risk of developing, or hasten the progression AD if an increase in the level of AP 42 in the biological composition exposed to the agent is observed when compared with the level of AJ3 42 in the biological composition not exposed to the agent In another embodiment, the invention provides a composition consisting of an A03 42 lowering agent and an antioxidant. The antioxidant can be, without limitation, vitamin E, vitamin C, curcumin, and Gingko biloba.

In another embodiment, the invention provides a composition consisting of an AJ3 42 lowering agent and a non-selective secretase inhibitor.

In another embodiment, the invention provides a composition consisting of an

AP

42 lowering agent and an acetylcholinesterase inhibitor.

In another embodiment, the invention provides its containing an Af3 42 kt lowering agent and an antioxidant; an AP 42 lowering agent and a non-selective 0 0 secretase inhibitor, or an Ap 42 lowering agent and an acetylcholinesterase inhibitor.

Kits can include instructions that indicate dose regimens for the Ap 42 lowering agent, the antioxidant, the secretase inhibitor, and/or the acetylcholinesterase inhibitor.

In another embodiment, the invention provides for the use of an Ap 42 lowering agent in the manufacture of a medicament for the treatment of AD. When administered to O a patient, the medicament containing the Ap 42 lowering agent is effective for reducing 00 Ap 42 levels without affecting A3p4 levels. The medicament also can increase Ap 38 levels, 0 and may also increase Ap 34 Ap 3 6 Ap 37 or AP 39 levels. The Ap 42 lowering agent in the medicament can be an aryl propionic acid derivative, an aryl acetic acid derivative, or an amino carboxylic acid derivative. More specifically, the Ap 42 lowering agent in the medicament can be a structural derivative of an NSAID selected from the group consisting of flufenmic acid, meclofenamic acid, fenoprofen, carprofen, ibuprofen, ketoprofen, and flurbiprofen. The Ap 42 lowering agent also can be a structural derivative of 5-nitro-2-(3-phenylpropylamino)benzoic acid). The Ap 42 lowering agent in the medicament can lack COX-1, COX-2, or both COX-1 and COX-2 inhibiting activity.

The AP 42 lowering agent in the medicament can have a greater potency, in vivo, for lowering Ap 42 levels than for inhibiting COX-1, COX-2, or both COX-1 and COX-2 activity. The medicament can be used to treat AD in a mammal such as a human. The medicament can be used in a mammal that has not been diagnosed with AD, or in a mammal that does not have a genetic predisposition for AD.

The term "Ap 42 lowering agent" as used herein refers to an NSAID, an NSAID derivative, an NSAID analogue, or any compound that has the ability to reduce Ap 42 levels, has the ability to increase Ap 3 s levels, and has no affect on Ap4o levels.

The AP 42 lowering agent also can increase the levels of one of Ap 34 Ap 36 Ap 37 or Ap 39 The AP 42 lowering agent can be a derivative of aryl propionic acid, aryl acetic acid, or amino carboxylic acid. The Ap4 2 lowering agent can be a derivative of an NSAID such as flufenmic acid, meclofenamic acid, fenoprofen, carprofen, ibuprofen, ketoprofen, and flurbiprofen. The Ap 42 lowering agent can lack COX-1, COX-2, or both COX-1 and COX-2 inhibiting activity; or have a much greater potency, in vivo, for lowering Ap 42 relative to COX-1, COX-2, or both COX-1 and COX-2 inhibiting activity.

As used herein, the terms "increase" and "decrease," refer to a change in any amount that is reproducible and significant A reproducible and significant change is differentiated from irreproducible or insignificant experimental variations in measurements by standard statistical analysis methods including analysis that involves c- 5 comparison with changes observed for control agents known to have no effects on the levels of the AP3 forms of interest. A significant change can be any amount such as a 1, 5, 10, 20, 40 or more thani 40% increase or decrease.

0C) Unless otherwise defined, all technical and scientific terms used herein have the C) same meaning as commonly understood by one of ordinary skill in the art to which this C) 10 invention pertains. Al1though methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting.

Other features and advantages of the invention will be apparent from the following detailed description, and from the claims.

DESCRIPTION OF DRAWINGS Figure 1 is a bar graph summarizing A[3 42 /Ap 4 o ratios and total AP3 levels determined for CHO cells expressing APP751 and PS-i mutant M146L that had been treated with DMSO or with various concentrations of sulindac; sulfide.

Figure 2 is a bar graph smarizing AJ3 42

/AP

40 ratios and total AP3 levels determined for human neuroglioia, cells (HS683) expressing APP695 that had been treated with DMS0 or with various concentrations of sulindac; sulfide.

Figure 3 is a bar graph summarizing AP 42 /A3P.o ratios and total AP3 levels determined for CHO cells expressing APP751 and PS-i mutant M146L that had been treated with ethanol or with various concentrations of ibuprofen.

in Figure 4 is a bar graph summarizing Ap3 42 /A40 ratios and total AP3 levels determined for O CHO cells expressing APP751 and PS-1 mutant M146L that had been treated with SDMSO or with various concentrations ofindomethacin.

Figure 5 is a bar graph summarizing AP 42 /Ap 4 o ratios and total AP levels determined for CHO cells expressing APP751 that had been treated with DMSO or with various concentrations ofnaproxen.

00 C- Figure 6 is a bar graph comparing Ap 42 /Ap 4 o ratios and total AP levels in CHO cells expressing APP751 that had been treated with ethyl acetate or various concentrations of C-I celecoxib.

Figure 7 is a bar graph summarizing Ap 42 /Ap 4 o ratios and total AP levels determined for primary fibroblasts (from COX-1/ COX-2 double-knockout mice) expressing APP 695 that had been treated with DMSO or various concentrations of sulindac sulfide.

Figure 8 is two representative mass spectra of AP species secreted by CHO cells expressing APP751 after treatment with DMSO or 100 pM sulindac sulfide.

Figure 9 is a bar graph illustrating ratios of APi.42, AP.- 39 API-3s., and ApI- 37 to APi-4o in cells treated with DMSO or sulindac sulfide.

Figure 10 is a scattergram of Ap 4 o and A0 42 levels in the brains of Tg2576 mice after short-term NSAID treatment Figure 11 is a summary of the structures ofindomethacin and meclofenamic acid, possible side chain modifications, and the effects of these modifications on COX-1 and COX-2 activities.

Figure 12 is a compilation of the structures of newly synthesized biphenyl amines.

Figure 13 is a time course of Ap 42 reduction in CHO APP695NL,I,his cell cultures treated with meclofenamic acid.

DETAILED DESCRIPTION c 5 The invention relates to the use of Ap 42 lowering agents to prevent, delay, or reverse the progression of AD. The invention is based on the discovery that some but not Sall NSAIDs useful for treating AD are those that can reduce the level of the pathogenic 00 C AP 42 form and increase the levels of Ap forms smaller than Ap40 such as Ap3s.

C-N Therefore, the invention provides methods and materials related to identifying Ap 42 0 10 lowering agents, including NSAIDs, NSAID derivatives, and NSAID analogues that (1) c-i can reduce the level of Ap 4 2 by reducing APP processing into Ap 42 or by increasing Ap 42 catabolism; increase the level of Ap 3 s by increasing APP processing into Ap 38 and (3) have increased selectivity for reduction of Ap 42 relative to inhibition of COX-1, COX-2, or both COX-1 and COX-2. In addition, the invention provides methods and materials related to identifying agents that can increase the risk of, or hasten the progression of, AD in a mammal, by increasing the processing of APP into Ap 42 or decreasing the catabolism of Ap 42 The invention also provides compositions and kits that can be used to prevent, delay, or reverse the progression of AD.

1. Af842 lowering agents Ap 42 lowering agents include, without limitation, NSAIDs, NSAID derivatives, and NSAID analogues. NSAIDs can be FDA-approved NSAIDs. NSAID derivatives are compounds generated by modifying functional groups of known NSAIDs. Once modified, derivatives may or may not have the anti-inflammatory properties of the parent NSAIDs. Structural analogues of NSAIDs are compounds that are structurally similar to NSAIDs. Analogues also may not have the anti-inflammatory properties of the corresponding structurally similar NSAIDs to which they resemble.

NSAIDs are non-steroidal anti-inflammatory drugs that are distinct from steroidal drugs with anti-inflammatory properties such as corticosteroids. NSAIDs, many of which are organic acids, typically have analgesic (pain-killing), anti-inflammatory, and antipyretic (fever-reducing) properties. Some examples of NSAIDs include salicylic acid S(Aspirin), ibuprofen (Motrin, Advil), naproxen (Naprosyn), sulindac (Clinoril), diclofenac 0(Voltaren), piroxicam (Feldene), ketoprofen (Orudis), diflunisal (Dolobid), nabumetone S(Relafen), etodolac (Lodine), oxaprozin (Daypro), Meclofenamic acid (Meclofen) and indomethacin (Indocin). NSAIDs can be grouped into classes, for example, amino aryl carboxylic acid derivatives flufenamic acid, meclofenamic acid); aryl acetic acid derivatives indomethacin, sulindac); and aryl propionic acid derivatives S(fenoprofen, ibuprofen, carprofen).

00 Although NSAIDs have multiple cellular effects (see Cronstein et al. (1995) Annu 0 Rev Pharmacol Toxicol 35:449-62; and Amin et al. (1999) Cell Mol Life Sci 56:305-12), t 10 many act through direct inhibition of COX enzymes. COX enzymes oxidize arachidonic 0 acids from membrane bound phospholipids to prostaglandins (see Smith et al. (2000) Ann Rev Biochem 69:145-82). Inhibition of COX enzymes and therefore prostaglandin synthesis is believed to underlie the analgesic and anti-inflammatory properties of aspirin and NSAIDs (see Dubois et al. (1998) FASEB J 12:1063-73). There are two isoforms of COX: COX-1 and COX-2. Although COX-1 and COX-2 catalyze the same reaction, they are derived from two different genes. COX-1 is traditionally viewed as a constitutive or housekeeping enzyme while COX-2 is viewed as an inducible enzyme that is expressed during inflammatory circumstances. COX products, primarily prostaglandin E2, modulate classical signs of inflammation. Another COX product is thromboxane A2 that promotes platelet aggregation and vasoconstriction. Although COX is expressed in neurons, its function in the central nervous system is unclear.

Another target of NSAIDs is the peroxisome proliferator-activator receptor (PPAR) family of nuclear hormone receptors. The PPAR family consists of at least three subtypes: PPARa, PPAR8, and PPARy (see Corton et al. (2000) Annu Rev Pharmacol Toxicol 40:491-518). These receptors are thought to function as ligand-dependent activators of transcription. All three PPAR members are modulated by NSAIDs, although in different ways. For example, NSAIDs activate the activities ofPPARa and PPARy but inhibit PPAR8 activity (see He et al. (1999) Cell 99:335-45). It is known that PPARy expression is increased in brains of AD individuals (Kitamura et al. (1999) Biochem Biophys Res Commun 254:582-6), and that PPARy agonists block AP-stimulated secretion ofproinflammatory products ofmicroglia, including IL-1 and TNF-a (see Combs et al. (2000) JNeurosci 20:558-67). It has been suggested that the beneficial 8 effects ofNSAIDs in AD may be mediated via their activity on PPARy rather than or in C' addition to COX inhibition (Combs et al. (2000) JNeurosci 20:558-67). It is not known, however, what downstream genes are activated by PPARs, or whether they are involved in Ap production.

An AP 42 lowering agent is any compound that has the following three properties: the ability to reduce the level of Ap 42 either through reducing APP processing or increasing AP 42 catabolism, no effect on the level of Ap40, and and the ability to 00 increase AP 38 These three properties differentiate AP 42 lowering agents of the invention Sfrom other compounds having COX inhibiting activities or those that do not selectively reduce Ap 42 production. These three properties are referred to collectively as the Alzheimer's-Ap 42 -NSAID (Ap 42 -NSAID) footprint. In addition to having the Ap 42 NSAID footprint, an AP 42 lowering agent of the invention can modulate the level of Ap forms smaller than AP40 such as Ap 34 Ap 36

AP

37 and Ap39.

2. Identification of A42 lowering agents useful for treating AD

AP

42 lowering agents can be identified from collections ofNSAIDs, NSAID derivatives, NSAID analogues, or other compounds using the Ap 42 -NSAID footprint.

Such compounds can be obtained from any commercial source. For example, NSAIDs, NSAID derivatives, and NSAID analogues can be obtained from Sigma, Biomol, Cayman Chemical, ICN, or from the web through the Chemnavigator website. Novel NSAIDs, novel NSAID derivatives, and novel NSAID analogues can be chemically synthesized using methods described in many published protocols. NSAIDs, NSAID derivatives, and NSAID analogues can be synthesized with altered potency for their known targets such as COX-1 and COX-2. For example Kalgutkar et al. (2000) PNAS 97:925-930 have made derivatives of indomethacin and meclofenamic acid and Bayly et al (1999) Biorg and Med Chem Letters 9:307-312 have made derivatives of Flurbiprofen. Indeed, because of the effort to engineer NSAIDs so that they preferentially inhibit COX-2 rather than nonselectively inhibit COX-1 and COX-2, there are dozens of published reports documenting synthesis of novel derivatives of known NSAIDs (reviewed in Dewitt (1999) Molecular Pharmacology 55:625-631).

It is recognized that some NSA]]) derivatives or MSAID analogues generated can have increased potency for lowering AP3 42 levels and decreased potency for COX inhibition. Although derivatives and analogues may no longer be considered NSAfl~s since they may lack anti-inflammatory properties, AP 42 lowering agents can include such N- 5 NMAID derivatives and NSAID analogues.

AP

42 lowering agents that have the Af3 42 -NSAIl) footprint can be identified using cell free assays, in vitro cell-based assays, and in vivo animal studies. AJ3 42 lowering 00 agents can be dissolved in any suitable vehicle for in vitro cell culture studies or in vivo c-I animal or human studies. A vehicle is an inert solvent in which a compound can be dissolved for administration. It is recognized that for any given Aj3 42 lowering agent, a c-I vehicle suitable for in vitro cell culture studies or in vivo animal studies may not be the same as the vehicle used for human treatment. Some examples of suitable vehicles for cell culture or animal studies include water, dimethyl sulfoxide, ethanol, and ethyl acetate.

To identify AP3 42 lowering agents that reduce APP processing, a biological composition having an APP processing activity an activity that processes APP into various AP3 forms, one of which is A03 42 is incubated with APP under conditions in which APP processing occurs. To identify AJ3 42 lowering agents that increase Aj3 42 catabolism, a biological composition having A{342 catabolic activity is incubated with Af3 42 under conditions in which A3 42 catabolism occurs. Depending on the nature of the biological composition, the APP or Aj3 42 substrate can be added to the biological composition, or, each or both can be a component of the biological composition. APP processing or AJ3 42 catabolism is allowed to take place in the presence or absence of the candidate AP 42 lowering agent. The level of AP 42 generated from APP processing or the level of A0 42 remaining after the catabolic reaction, in the presence and absence of the candidate AP 42 lowering agent, is determined and compared. AP 42 lowering agents useful for treating AD are those that reduce the level of Af3 42 either by reducing APP processing into AP 42 or by enhancing AP 42 catabolism and increasing A1338 production.

The biological composition having an APP processing and/or catabolic activity can be a cell-free biological sample. For example, a cell-free biological sample can be a purified or partially purified enzyme preparation; it also can be a cell lysate generated Sfrom cells able to process APP into A0 42 or from cells able to catabolize Ap 42 Cell Clysates can be prepared using known methods such as, for example, sonication or Sdetergent-based lysis. In the case of an enzyme preparation or cell lysate, APP can be added to the biological composition having the APP processing activity, or Ap4 2 can be added to the biological composition having Ap 42 catabolic activity.

In addition, the biological composition can be any mammalian cell that has an SAPP processing activity as well as a nucleic acid vector encoding APP. Alternatively, the biological composition can be any mammalian cell that has AP catabolic activity as well Sas a nucleic acid vector or a viral nucleic acid-based vector containing a gene that encodes Ap 42 The vector typically is an autonomously replicating molecule, a molecule that does not replicate but is transiently transfected into the mammalian cell, or a vector that is integrated into the genome of the cell. Typically, the mammalian cell is any cell that can be used for heterologous expression of the vector-encoded APP or Ap 42 in tissue culture. For example, the mammalian cell can be a Chinese hamster ovary (CHO) cell, a fibroblast cell, or a human neuroglioma cell. The mammalian cell also can be one that naturally produces APP and processes it into Ap 42 or one that naturally produces and catabolizes Ap42.

Further, the biological composition can be an animal such as a transgenic mouse that is engineered to over-express a form of APP that then is processed into Ap 42 Alternatively, the animal can be a transgenic mouse that is engineered to over-express

AP

42 Animals can be, for example, rodents such as mice, rats, hamsters, and gerbils.

Animals also can be rabbits, dogs, cats, pigs, and non-human primates, for example, monkeys.

To perform an in vitro cell-free assay, a cell-free biological sample having an activity that can process APP into AP 42 is incubated with the substrate APP under conditions in which APP is processed into various AP forms including Ap 4 2 (see Mclendon et al. (2000) FASEB 14:2383-2386. Alternatively, a cell-free biological sample having an activity that can catabolize Ap 42 is incubated with the substrate Ap 42 under conditions in which Ap 42 is catabolized. To determine whether a candidate Ap 42 lowering agent has an effect on the processing of APP into Ap 42 or the catabolism of

AP

42 two reactions are compared. In one reaction, the candidate Ap 42 lowering agent is included in the processing or catabolic reaction, while in a second reaction, the candidate 0

A

42 lowering agent is not included in the processing or catabolic reaction. Levels of the different AP forms produced in the reaction containing the candidate AP 42 lowering agent are compared with levels of the different AP forms produced in the reaction that does not C- 5 contain the candidate Ap 42 lowering agent.

The different AP forms can be detected using any standard antibody based assays such as, for example, immunoprecipitation, western hybridization, and sandwich enzyme- 00 linked immunosorbent assays (ELISA). Different Ap forms also can be detected by mass Sspectrometry; see, for example, Wang et al. (1996) JBiol Chem 271:31894-902. Levels of Ap species can be quantified using known methods. For example, internal standards N can be used as well as calibration curves generated by performing the assay with known amounts of standards.

In vitro cell-based assays can be used determine whether a candidate AP 42 lowering agent has an effect on the processing of APP into Ap 42 or an effect on catabolism of Ap 42 Typically, cell cultures are treated with a candidate Ap 42 lowering agent. Then the level of A 42 in cultures treated with a candidate Ap 42 lowering agent is compared with the level of Ap 42 in untreated cultures. For example, mammalian cells expressing APP are incubated under conditions that allow for APP expression and processing as well as Ap 42 secretion into the cell supernatant. The level of Ap 42 in this culture is compared with the level of Ap 42 in a similarly incubated culture that has been treated with the candidate Ap 42 lowering agent. Alternatively, mammalian cells expressing AP 42 are incubated under conditions that allow for Ap 42 catabolism. The level of AP 42 in this culture is compared with the level of AP 42 in a similar culture that has been treated with the candidate Ap 42 lowering agent.

In vivo animal studies also can be used to identify AP 42 lowering agents useful for treating AD. Typically, animals are treated with a candidate Ap 42 lowering agent and the levels of AP 42 in plasma, CSF, and/or brain are compared between treated animals and those untreated. The candidate Ap4 2 lowering agent can be administered to animals in various ways. For example, the candidate Ap 42 lowering agent can be dissolved in a suitable vehicle and administered directly using a medicine dropper or by injection. The candidate AP 42 lowering agent also can be administered as a component of drinking water or feed. Levels of Ap in plasma, cerebral spinal fluid (CSF), and brain are determined CI using known methods. For example, levels of AP 42 can be determined using sandwich ELISA or mass spectrometry in combination with internal standards or a calibration curve. Plasma and CSF can be obtained from an animal using standard methods. For example, plasma can be obtained from blood by centrifugation, CSF can be isolated using standard methods, and brain tissue can be obtained from sacrificed animals.

When present in an in vitro or in vivo APP processing or AJ0 42 catabolic reaction, Aj3 42 lowering agents reduce the level of AJ3 42 generated by APP processing or remang following AJ3 catabolism. For example, in an in vitro cell-free assay, the level of AJ3 42 is reduced due to either a reduction of APP processing or an increase in AP 42 catabolism in the presence the A13 42 lowering agent In an in vitro cell culture study, a reduction in the level of A13 42 secreted into the supernatant results from the effect of the A0 42 lowering agent on either a reduction in processing of APP into A13 42 or an increased catabolism of

AP

42 Similarly, in animal studies, a reduction in the level of Aj3 42 that can be detected in plasma, CSF, or brain is attributed to the effect of the A(3 42 lowering agent on either a reduction in the processing of APP into Af3 42 or an increase in the catabolism of Af3 42 The level of A0 42 can be reduced by a detectable amount For example, treatment with an A0 42 lowering agent leads to a 0.5, 1, 3, 5, 7, 15, 20, 40, 50, or more than reduction in the level of AP 42 generated by APP processing or remaining following Aj3 42 catabolism when compared with that in the absence of the Aj3 42 lowering agent.

Preferably, treatment with the AP 42 lowering agent leads to at least a 20% reduction in the level of AP 4 7 generated when compared to that in the absence of Af3 42 lowering agent More preferably, treatment with an AP 42 lowering agent leads to at least a 40% reduction the level of A0 42 when compared to that in the absence of an AP 42 lowering agent.

Typically, the A0 42 lowering agent-associated reduction of APl 4 2 levels is accompanied by an increase in the level of A0l 3 8. In contrast, no change is observed in (1) the level of Ap 4 o generated by APP processing or A0 42 catabolism in cell-free assays, (2) the level of Aj3 4 0 secretion into culture supernatants in cell-based assays, or the level of AP 4 0 detected in blood plasma, CSF, or brains of animals treated with AP 42 lowering agent.

AP

42 lowering agents of the invention may lack COX inhibitory activity or have 0 reduced COX-1, COX-2, or both COX-1 and COX-2 activity. COX inhibitory activity Scan be determined using known methods. For example, COX inhibitory activity can be determined using the method described in Kalgutkar et al. (2000) PNAS 97:925-930.

5 A method to identify NSAID derivatives and NSAID analogues that possess AP42 lowering ability and have altered COX activity is described. NSAID derivatives and SNSAID analogues of aminocarboxylic acids, arylacetic acids and arylpoprionic acids can 00 Sbe tested for their ability to lower Ap 42 and increase Ap 38 in cultured cells and in animals c0 (as described herein). They also can be tested simultaneously for their ability to inactivate COX-1 and COX-2 using in vitro assays as described by Kalgutkar et al.

CN (2000) PNAS 97:925-930. Derivatives of the NSAIDs sulindac, meclofenamic acid, flufenamic acid, indomethacin, carprofen, fenoprofen, and flurbiprofen that can be tested include the following: meclofenamic acid and flufenamic acid derivatives in which the position of the carboxylic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the caraboxylic acid substituent are altered, (c) the bond connecting the two phenyl rings is altered, the carboxylic acid substituent is altered to a propionic acid or other derivative, or any combination of these alterations; fenoprofen, flurbiprofen, and carprofen derivatives in which the position of the propionic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, the acetic acid substituent is altered to a carboxylic acid or other derivative, or any combination of these alterations; indomethacin derivatives in which the carboxylic acid group on indomethacin is altered to other substituents, the substituent on the indole nitrogen is altered, or any combination of the two; sulindac sulfide in which the methylthio derivative of sulindac sulfide is altered to other substituents, the propionic acid derivative is altered to other substituents, the Fluoride is altered to other substituents, or any combination of the above.

In addition structural analogues ofNSAIDs that possess Ap42 lowering ability, identified by pharamacophore searches (Perola et al., (2000) J. Med Chem.43: 401-408) or other computer based structural comparison programs of commercially available compounds can be tested for AP 42 lowering activity, ability to increase A3 38 and COX inhibition as described herein.

N 5 3. Identification of mammals in need of treatment with an Af 42 lowering agent Clinical symptoms of AD) include, for example, progressive disorientation, memory loss, and aphasia; eventually, disablement, muteness, and immobility occur.

Pathological indicators of AD) include, for example, the presence of neurofibrillary tangles, neuritic plaques, and amyloid angiopathy. Preventing the progression of AD can be interpreted to mean preventing the onset or fur-ther development of clinical symptoms N and/or pathological indicators of AD. For example, an individual who does not have clinical symptoms or pathological indicators of AD can be prevented from developing clinical symptoms or pathological indicators. Further, an individual who has a mild form of AD can be prevented from developing a more severe form of AD. Delaying the progression of AD can be interpreted to mean delaying the time of onset of AD-related symptoms and/or pathological indicators or slowing the rate of progression of AD, determined by the rate of development of clinical symptoms and pathological indicators.

Reversing the progression of AD can be interpreted to mean that the severity of an AD condition has been lessened, the AD condition of an individual has changed from severe to less severe as indicated by fewer clinical symptoms or pathological indicators.

An individual can choose to take an A13 42 lowering agent as a preventative measure to avoid developing AD. For example, an individual with a genetic predisposition to AD can take an A13 42 lowering agent to prevent or delay the development of AD. A genetic predisposition can be determined based on known methods. For example, an individual can be considered to have a genetic predisposition to AD if the individual has a family history of AD. Genetic predisposition to AD also can include point mutations in certain genes such as the APP gene, the presenilin-l or presenilin-2 gene, or the apolipoprotein E gene. Such mutations can predispose individuals to early-onset familial AD (FAD), increased risk of developing AD, or decreased age at onset of AD. (See page 1332, Table 30-2 of Cotran et al. (1999) Robbins Pathologic Basis of Disease, Sixth Edition, W.B. Saunders Company; and U.S.

Patent No. 5,455,169.) Furthermore, an individual who has clinical symptoms of, or has n been diagnosed with, AD can take an AP 42 lowering agent to prevent or delay further Sprogression of AD as well as to reverse the pathological condition of the disease.

SAn AD diagnosis can be made using any known method. Typically, AD is diagnosed using a combination of clinical and pathological assessments. For example, cNi 5 progression or severity of AD can be determined using Mini Mental State Examination (MMSE) as described by Mohs et al. (1996) Int Psychogeriatr 8:195-203; Alzheimer's Disease Assessment Scale- cognitive component (ADAS-cog) as described by Galasko et 0 al. (1997) Alzheimer Dis Assoc Disord, 11 suppl 2:S33-9; the Alzheimer's Disease O Cooperative Study Activities of Daily Living scale (ADCS-ADL) as described by McKhann et al. (1984) Neurology 34:939-944; and the NINCDS-ADRDA criteria as Sdescribed by Folstein et al. (1975) JPsychiatr Res 12:189-198. In addition, methods that allow for evaluating different regions of the brain and estimating plaque and tangle frequencies can be used. These methods are described by Braak et al. (1991) Acta Neuropathol 82:239-259; Khachaturian (1985) Arch Neuro 42:1097-1105; Mirra et al.

(1991) Neurology 41:479-486; and Mirra et al. (1993) Arch Pathol Lab Med 117:132- 144.

4. Treatment of mammals with Af8 4 2 lowering agents Ap 42 lowering agents can be administered in any standard form using any standard method. For example, Ap 42 lowering agents can be in the form of tablets or capsules that are taken orally. Ap 42 lowering agents also can be in a liquid form that can be taken orally or by injection. Ap 42 lowering agents also can be in the form of suppositories.

Further, Ap 42 lowering agents can be in the form of creams, gels, and foams that can be applied to the skin, or in the form of an inhalant.

Ap 42 lowering agents can be administered at any dose that is sufficient to reduce levels of AP 42 in the blood plasma, CSF, or brain. Lower doses can be taken over a period of years to prevent and/or delay the progression of AD. Higher doses can be taken to reverse the progression of AD. Depending on the effectiveness and toxicity of a particular Ap 42 lowering agent, an A3 42 lowering agent can be used at a dose of 0.1-50 mg/kg/day.

Compositions and kits The invention also provides pharmaceutical compositions containing combinations of an A3 42 lowering agent and an antioxidant effective in preventing, delaying, or reversing the progression of Alzheimer's disease. An A0 4 2 lowering agent of the invention that has the ability to reduce AP42 levels can be combined with any antioxidant. The antioxidant can be a vitamin, for example vitamin E, vitamin C or curcumin; the antioxidant also can be Gingko biloba. Other pharmaceutical compositions 00 can include an AP 4 2 lowering agent and a non-selective secretase inhibitor or an acetylcholinesterase inhibitor.

The pharmaceutical composition can be in any form, for example tablets, capsules, liquids, creams, gels, or suppositories and can include a suitable pharmaceutical carier. In addition, the invention provides kits containing pharmaceutical compositions of AP3 42 lowering agents and antioxidants as well as instructions that indicate dose regimens for effective use.

The invention will be further described in the following examples, which do not limit the scope of the invention described in the claims.

EXAMPLES

Example 1 Cell cultures, drug treatments, and cell toxicity analysis Cell cultures were maintained in standard cell culture media supplemented with fetal bovine serum and 100 U/mL penicillin/streptomycin (Life Technologies Inc., Germany). Cell cultures consisted of the following: Chinese hamster ovary (CHO) cells that expressed human APP751 from a vector containing a gene encoding APP75 1; CHO cells that expressed both human APP751 and human mutant PS-1 (M146L) from vectors containing genes encoding APP751 and mutant PS-1 (M146L); CHO cells that expressed human mutant APP751 (V717F) from a vector containing a gene encoding mutant APP751 (V717F); human neuroglioma cells HS683 that expressed human APP695 from a vector containing a gene encoding APP695; HEK 293 cells that expressed human APP695 from a vector containing a gene encoding APP695; and embryonic fibroblasts (that had immortalized spontaneously) from COX-1 and COX-2 double-knockout mice.

The NSAJDs, sulindac sulfide (50 mM, Biomol, PA, USA), sulindac sulfone mM, Biomol, PA, USA), naproxen (100 mM, Cayman Chemical, MI, USA), and aspirin M, ICN Biomedicals, CA, USA) were dissolved in the vehicle DMSO.

(C Indomethacin (50 mM, Biomol, PA, USA) and (S)-ibuprofen (250 mM, Biomol, PA, SUSA) were dissolved in ethanol. Celecoxib and rofecoxib capsules were obtained from and dissolved in ethyl acetate. For analyses of A3 secretion, APP processing, and notch N 5 cleavage, cells were cultured in serum-containing media and pretreated overnight with a specific NSAID. The next day, media were changed and cultures were treated with the same NSAID for another 24 hours.

00 SNSAID toxicity in CHO or HS683 cells was examined using standard MTT-assay N 3 -(4,5-Dimethyl-2-thiazolylyl)-2,5-diphenyl-2H-tetrazolium Bromide) or 3 H]-thymidine O 10 incorporation assay. For cell toxicity studies, cells were treated with sulindac sulfide at c- concentrations up to 100 pM, indomethacin at concentrations up to 200 pM, and ibuprofen at concentrations up to 1mM.

Example 2 Antibodies Antibodies used included the following: 5A3 and 1G7, two monoclonal antibodies that recognized non-overlapping epitopes between residues 380-665 of APP; CT15, a polyclonal antibody that recognized the C-terminal fifteen amino acid residues of APP; 26D6, a monoclonal antibody that recognized amino acid residues 1-12 of the Ap sequence; 9E10, a monoclonal antibody that recognized the myc-epitope sequence; anti- COX-2 antibody, a monoclonal antibody that recognized COX-2; and M-20, a polyclonal antibody that recognized COX-1. The antibodies 5A3, 1G7, CT15, and 26D6 were described by Koo et al. (1996) J Cell Sci 109:991-8; Sisodia et al. (1993) JNeurosci 13:3136-42; and Lu et al. (2000) Nat Med 6:397-404. The monoclonal antibody 9E10 was purchased from Calbiochem-Novobiochem, CA, USA. The monoclonal anti-COX-2 antibody was purchased from BD Transduction Laboratories, CA, USA. The polyclonal antibody M-20 was purchased from Santa Cruz Biotechnology, CA, USA.

Example 3 ELISA Ap was detected by sandwich enzyme-linked immunosorbent assay (ELISA) as described by Murphy et al. (2000) JBiol Chem 275:26277-84. Following NSAID treatment, culture supernatants were collected, and cell debris was removed by centrifugation. Complete protease inhibitor cocktail (Roche Molecular Biochemicals, IN, USA) was added to the media and AP 4 o and AP 42 levels were quantified using end- C' specific Ap ELISAs. All measurements were performed in duplicate.

Example 4- Adenoviral infection of embryonic fibroblasts derived from COX-1/COX-2 5 double-knockout mice The adenoviral vector containing a gene encoding APP695 was described by Yuan et al. (1999) JNeurosci Methods 88:45-54. Primary fibroblasts derived from COX- 00 1l/COX-2 double-knockout mice were infected with 100 plaque-forming units (PFU) of

C

N1 viral vector per cell. Infection was performed in serum-free medium for two hours.

Medium was changed and cells were treated with NSAIDs as described in Example 1.

Example 5 -Analyses ofAPP and Notch processing Expression ofholo-APP and APP C-terminal fragments (CTFs) was examined by Western blot analysis using antibody CT-15. APP secretion was examined by Western blotting using a mixture of 5A3/IG7 antibodies. APP turnover was examined by pulse labeling of CHO cells with 150 gCi 3 5 S]-methionine for fifteen minutes followed by a cold chase step for up to four hours. Cell lysates were immunoprecipitated with antibody subjected to SDS-PAGE, and analyzed by phosphor imaging.

APP surface expression and internalization were measured as described by Koo et al. (1996) JCell Sci 109:991-8. lodinated antibody 1G7, at approximately 3-6 tCi/tg, was applied to confluent layers of CHO cells in binding medium (DMEM, 0.2% BSA, mM HEPES [pH and incubated at 37 °C for thirty minutes. After incubation, cells were rapidly chilled on ice and the reaction was quenched by the addition of ice-cold binding medium. To remove unbound antibody, chilled cells were washed multiple times with ice-cold Dulbecco's phosphate-buffered saline (Life Technologies Inc.). Antibody bound to cell surface APP was detached by washing with ice-cold PBS (pH 2) for five minutes; this constituted the acid-labile APP antibody pool. Cells were lysed in 0.2 M NaOH; lysates contained the acid-resistant APP antibody pool. Acid-labile and acidresistant APP antibody counts were measured by y counting. The ratio of acid-resistant to acid-labile count was a measure of the internalized to the cell surface APP pool.

Two Notch-encoding vector constructs were used in examining Notch processing.

These were a construct expressing a myc-tagged NH 2 -terminal truncated Notch-1 polypeptide (NotchAEMV), and a construct expressing only the Notch intracellular c cytoplasmic domain (NICD) (see Kopan et al. (1996) Proc NatlAcad Sci USA 93:1683- S8). In the construct expressing a myc-tagged NH 2 -terminal truncated Notch-1 polypeptide, the start codon, a methionine at position 1726, was mutated to a valine to c1 5 eliminate translation initiation.

Example 6 Mass spectrometry 00 Secretion of AP peptides was analyzed using immunoprecipitation/mass N spectrometry as described by Wang et al. (1996) JBiol Chem 271:31894-902. Briefly, 1 0 10 mL amount of culture supernatant was subjected to immunoprecipitation using the 0 c,1 monoclonal antibody 4G8 (Senetek, CA, USA). Molecular masses and concentrations of AP peptides were measured using a matrix assisted laser desorption/ionization time-offlight (MALDI-TOF) mass spectrometer. To compare the concentrations of individual Ap species in culture supematants, synthetic AI32-28 peptides (Sigma, MO, USA) were added to the supernatant samples as internal standards and relative peak heights were calculated.

Example 7 Bicine/Urea A6 western blot analysis Bicine/Urea AP western blot analysis was performed as described by Wiltfang et al. (1997) Electrophoresis 18:527-32. A 1 mL amount of culture supematant was subjected to immunoprecipitation using monoclonal antibody 26D6. Immunoprecipitates were mixed with sample buffer and heated to 95 *C for five minutes. Eluant samples were separated on Bicine/Urea gels, then transferred to nitrocellulose membranes, and probed with antibody 26D6. Standard Api-4, Ap1- 42 and APi-3 8 peptides (Sigma, MO, USA) were used for identification of the AP species.

Example 8 Cells treated with the non-selective COX-inhibitor sulindac sulfide showed reductions in levels ofA/142 secretions Cell cultures were treated with increasing concentrations of the NSAID sulindac sulfide. Levels of AP40 and AP 42 in culture supematants were analyzed using ELISA.

Figure 1 is a graph comparing the Ap 42 /Ap 4 o ratios of sulindac sulfide-treated CHO cell cultures expressing APP751 and the PS-I mutant M146L. AP 42

/AP

4 o ratios and total AD3 levels the sum of AP40 and A0 42 values) were normalized to values obtained from DMSO-treated cells. Results shown were averages of two or three experiments performed in duplicate. CHO cell cultures treated with 40-60 pM sulindac sulfide Cl 5 showed a 50% reduction in AP42/Ap 4 o ratios. No significant reduction in total AD level was observed. Therefore, treatment of CHO cells expressing APP and mutant PS-1 with the NSAID sulindac sulfide reduced the AP 42 /Ap 4 o ratio by selectively reducing AP 42 00 secretion in a dose-dependent manner. This was confirmed in CHO cells that expressed wild type APP751 as well as those that expressed mutant APP V717F (data not shown).

To rule out potential cell type-specific effects, AD secretion in response to sulindac sulfide treatment was examined in the human neuroglioma cell line HS683 that expressed APP695. Figure 2 is a graph comparing AP 42 /AP40 ratios in HS683 cells expressing APP695 that were treated with DMSO with those of cells treated with various concentrations of sulindac sulfide. A dose-dependent reduction of A3 42 secretion, similar to that exhibited by CHO cells, was observed. Sulindac sulfide also reduced AP 42 secretion in kidney HEK293 cells and primary mouse embryonic fibroblasts (data not shown). No cell toxicity was observed at sulindac sulfide concentrations up to 100 AM (data not shown).

Example 9 Cells treated with other non-selective COX-inhibitors such as ibuprofen and indomethacin showed reductions in levels ofA3 42 secretion Cell cultures were treated with increasing concentrations of the NSAIDs ibuprofen and indomethacin. A0 4 o.and AP 42 levels in culture supernatants were analyzed using ELISA as described in Example 3. Figures 3 and 4 are graphs comparing AP3 42 ratios observed for CHO cells expressing APP751 and the PS-I mutant M146L when treated with various concentrations of ibuprofen and indomethacin, respectively.

AP

42

/A

4 o ratios and total AD levels were normalized to values obtained from ethanoltreated cells. Results shown were averages of two or three experiments, each performed in duplicate. Dose dependent reductions in AP 42

/AP

4 o ratios by selective reductions of AP3 42 secretion were observed for both ibuprofen and indomethacin. A 50% reduction in the AP 42 /Ap 4 o ratio was reached at ibuprofen concentrations between 200-300 pM and at Sindomethacin concentrations between 25-50 pM. Total AP levels were not significantly Ci affected at ibuprofen concentrations up to 500 pM (see Figure 3) and at indomethacin concentrations up to 100 pM (see Figure No cell toxicity was observed in CHO cells treated with ibuprofen concentrations up to lmM or indomethacin concentrations up to 200 pM (data not shown).

0 Example 10- Reduction of A042 secretion is not associated with COX-inhibitory activity or with all NSALDs The effect of sulindac sulfone on Ap42 secretion was examined. Sulindac sulfone S 10 is an oxidation product of the pro-drug sulindac. Like sulindac sulfide, sulindac sulfone inhibits proliferation and induces apoptosis in human cancer cell lines in vitro (see Piazza et al. (1995) Cancer Res 55:3110-6). In contrast to sulindac sulfide, sulindac sulfone is devoid of any inhibitory effect on COX. Cell cultures were treated with increasing concentrations of sulindac sulfone. Ap4o and AP 42 levels in culture supernatants were analyzed using ELISA. When CHO cells expressing APP 751 were treated with sulindac sulfone, no changes in Ap 42 /Ap 40 ratios were observed with sulindac sulfone concentrations of up to 400 pM (data not shown). The inability to reduce AP 42 secretion by the non-COX-inhibitor sulindac sulfone suggested an important mechanistic role for COX inhibition in the selective inhibition of Ap 42 secretion by NSAIDs.

To determine whether reduction of A3 42 secretion is a common effect of all NSAIDs, other clinically useful NSAIDs were examined. Naproxen is a non-selective COX-inhibitor with an inhibition profile similar to sulindac and a structure similar to ibuprofen (see Cryer et al. (1998) Am JMed 104:413-21). Cell cultures were treated with increasing concentrations of naproxen and aspirin. Ap4o and Ap 42 levels in cell culture supernatants were analyzed using ELISA. Ap 42 /Ap3 4 o ratios and total Aj3 levels were normalized to values obtained from DMSO-treated cultures. Averages of two or three experiments performed in duplicate are summarized in Figure 5. Treatment of CHO cells expressing APP751 with naproxen, at concentrations up to 400 pM, did not change Ap3 4 2/Ap40 ratios and did not affect total AP levels (see Figure Similarly, no reductions in A3 42 secretion were observed when cultures were treated with aspirin concentrations of up to 3 mM (data not shown). Two selective inhibitors of COX-2, Scelecoxib and rofecoxib, also were examined to determine if they reduced Ap 42 secretion.

C Celecoxib and rofecoxib were prepared from capsules using solvent extraction and Srecrystallization. NSAIDs were verified using NMR and mass spectrometry. CHO cells expressing APP751 were treated with various concentrations of celecoxib. Figure 6 is a c 5 bar graph comparing Ap 42 /Ap 40 ratios and total AP levels in cells treated with ethyl acetate or various concentrations of celecoxib. Results showed that 20pM celecoxib treatment induced a two-fold increase in Ap 4 2 /Ap 40 ratio. The increase in Ap 42 /Ap 40 ratio also was observed when human neuroglioma cells were tested (data not shown). The increase in Ap 42 /Ap 4 o ratio was not seen in cells treated with rofecoxib at 20 pM (data not shown). Diclofenac and NS-398, two other NSAIDs having preferential activities against COX-2, did not affect Ap 42 /Ap 4 o ratios or total Ap levels. Table 1 summarizes selective and non-selective COX-inhibitors that were tested and results of these tests. Reduction of

AP

42 secretion was not associated with all NSAIDs. (Note: peak NSAID concentrations used in these experiments were higher than what was required for complete inhibition of COX-1 and COX-2 activities in in vitro cell-based assays.) Table 1: Non-selective and selective COX-inhibitors tested for effect on A342 levels Drug Highest cone. tested Plasma Ap42/A340 ratio COX-l/COX-2 selectivity# Non-selective COX-inhibitors (l=equal activity) Sulindac sulfide 100 (pM) 14.6 (pM) selective decrease in A342 0.61 Indomethacin 150 1.4 selective decrease in Ap42 22-58 Ibuprofen 750 40-111 selective decrease in Ap42 1.69 Naproxen 400 1.3 no effect 1.79 Aspirin 3000 111 no effect 166 Meloxicam 100 15 no effect .01-0.3 Diclofenac* 600 6.1 no effect .69 Selective COX-2 inhibitors NS-398* 20 no effect .07 Celecoxib 20 (pM) 15 (nM) selective increase in A342 .003 Rofecoxib* 20 (pM) 3 (nM) no effect .001 To confirm that NSAID did not reduce AP 42 secretion through COX inhibition and though reduction ofprostaglandin synthesis, cells devoid of COX-1 and COX-2 activities were treated with sulindac sulfide, and Ap 42 /Ap 4 o ratios were examined. Primary fibroblasts derived from COX-1/COX-2 double-knockout mice, described by Zhang et al.

r (1999) JExp Med 190:451-59, were infected with an adenovirus vector that encoded SAPP695 (see Yuan et al. (1999) JNeurosci Methods 88: 45-54). Fibroblasts infected c-I Swith the adenovirus vector expressing APP695 were treated with increasing Sconcentrations of sulindac sulfide. Levels of AP forms in fibroblast culture supemrnatants C 5 were quantified using ELISA and results are summarized in Figure 7. (Ap 42 /Ap 4 o ratios and total AP3 levels were normalized to values obtained from DMSO-treated cells.

SResults were the averages of two or three experiments, each performed in duplicate.) Sulindac sulfide reduced A0 42 secretion as well as the Ap 42 /Ap4o ratio of fibroblasts in a N fashion similar to that seen with CHO and HS683 neuroglioma cells. Therefore, selective reduction of Ap3 42 was not mediated by COX inhibition.

Example 11 APP processing by a and 1-secretases, APP turnover, and notch intramembrane cleavage are not affected by sulindac sulfide NSAIDs are the only compounds reported so far that change Ap 42 /Ap4o ratios by selectively decreasing Ap 42 secretion. To determine if APP processing and notch intramembrane cleavage were affected in cells treated with NSAIDs, the following experiments were performed.

CHO cell cultures expressing APP751 were treated with increasing concentrations of sulindac sulfide. Cell lysates were prepared, and steady-state APP levels were examined using 4-12 gradient-gel electrophoresis and western blotting using the polyclonal antibody CT15. When western blot analysis was performed, neither a change in APP levels, nor an increase in CTF levels was observed in response to 60 pM or p.M sulindac sulfide treatment compared with levels observed for cells treated with DMSO. Unlike published y-secretase inhibitors, sulindac sulfide did not induce detectable accumulation of APP CTFs. Therefore, P-secretase cleavage was not significantly affected by sulindac sulfide.

When western blot analysis was performed to detect soluble APP (sAPP) in culture supemrnatants using 5A3/IG7 monoclonal antibodies, results showed that there was no significant change in secretion of the APP ectodomain, sAPP), in response to increasing concentrations of sulindac sulfide. Therefore, a-secretase cleavage was not significantly affected by sulindac sulfide.

APP turnover in the presence of sulindac sulfide was examined by pulse Slabeling CHO cells with 35 S-methionine and determination of APP half-life. All Svalues were normalized to a signal obtained at the end of pulse labeling. When the APP half-life in cells treated with DMSO was compared with APP half-life in cells treated C-I 5 with sulindac sulfide at 25 or 125 pM, APP half-life after treatment with 25 or 125 iM sulindac sulfide was similar to APP half-life after treatment with DMSO. Therefore, APP turnover was not altered significantly in the presence of sulindac sulfide.

00 A significant fraction of Al3 is produced and released in the endocytic pathway CN after internalization of APP from the cell surface (see Koo et al. (1994) JBiol Chem 269:17386-9). The effect ofsulindac sulfide on this endocytic pathway was examined NC- with an APP internalization assay described by Koo et al. (1996) J Cell Sci 109:991-8.

APP internalization was expressed as a ratio of cell surface APP versus internalized APP.

When APP internalization in cultures treated with DMSO was compared with APP internalization in cultures treated with sulindac sulfide at 60 or 80 pjM, the ratio of cell surface APP to internalized APP was not altered in cells treated with sulindac sulfide compared to cells treated with DMSO alone. Therefore, it was concluded that APP internalization was unchanged after sulindac sulfide treatment Notch intramembrane cleavage and formation of NICD were analyzed in kidney HEK293 cells. The myc-tagged NotchAEMV construct encoding a constitutively cleaved Notch variant was transiently transfected into HEK293 cells. Cell cultures were treated with 125 pM sulindac sulfide for 36 hours. Then they were pulse labeled with "3Smethionine for thirty minutes and chased for two hours. Cell lysates were prepared and subjected to immunoprecipitation with monoclonal antibody 9E10. Immunoprecipitated proteins were subjected to SDS-PAGE and phosphor imaging analyses. When amounts of NICD immunoprecipitated from lysates of cells treated with DMSO were compared with amounts immunoprecipitated from lysates of cells treated with sulindac sulfide, results showed that treatment with sulindac sulfide did not impair Notch cleavage and NICD formation. (Cells transfected with a construct encoding only the NICD domain were used for identification of the cleavage fragment.) Similarly, treatment with 500 pM ibuprofen or 150 pM indomethacin did not cause accumulation of APP-CTFs or inhibition of Notch cleavage (data not shown). Overall, these results demonstrated that NSAID treatment did not significantly perturb APP processing or y-secretase activity.

This, however, did not rule out modulation of y-secretase activity as a mechanism of action for NSAIDs. The selective reduction in AP 42 secretion could be reflected only in minor changes of y-secretase activity that may not be detectable in the assays described above.

Example 12 Reduction in A,6 42 secretion was accompanied by a dose-dependent 00 C increase in Al 1 3 s species NC< To examine AP species secreted by cells treated with sulindac sulfide, 0 10 immunoprecipitation and mass spectrometry analyses were performed. Figure 8 is two c representative mass spectra of AP species secreted by CHO cells expressing APP751 after treatment with DMSO or after treatment with 100 pM sulindac sulfide. After treatment with 75-100 uM sulindac sulfide, a strong reduction in AP 42 secretion was observed.

Levels of Ap40, however, were largely unaffected. Various AP species including ApI-4 2

API-

39 A3-.

3 s, and A3 1 37 were quantified. Figure 9 is a bar graph comparing ratios of each of these species to Ap3-4o0,i.e. APj-x/APi40o ratios, at 75 or 100 pIM sulindac sulfide.

Duplicate measurements were used in generating the bar graph. Reductions in Ap 42 /Ap4o ratios were accompanied by two-fold increases in A3i- 3 s/APi40o ratios. Increases in ApI3-3 levels were dose-dependent. Other AP peptide levels did not vary consistently between cells treated with DMSO or with sulindac sulfide.

Mass spectrometry results demonstrating reductions in Ap 42 secretion with concomitant increases in Api-3s secretion were confirmed by immunoprecipitation. AP polypeptides were immunoprecipitated from culture supematants of CHO cells expressing APP751 and mutant PS-1. Immunoprecipitates were separated on an SDSurea gel system that can resolve individual A3 species (see Wiltfang et al. (1997) Electrophoresis 18:527-32). Standard APi-3s, A3 1 -40, and A 1 i-4 2 peptides were included for identification of different AP species. When changes in Ap3s, A04o, and AP 42 levels in CHO cells treated with DMSO were compared with those in cells treated with 60 pM or 80 pM of sulindac sulfide, a reduction in the intensity of an immuno-reactive band corresponding to Ap 42 was observed. This reduction was matched by an equivalent increase in the intensity of an immuno-reactive band corresponding to Api- 3 s.

Two potential mechanisms may explain this unprecedented change in AP production after NSAID treatment. Sulindac sulfide could reduce Ap 42 secretion by CL. shifting y-secretase activity towards production of Ap~-3s. Alternatively, it may stimulate a novel proteolytic activity that converts Ap 42 into shorter Ap species such as AP 1 -3s.

Koo et al. (1994) JBiol Chem 269:17386-9 and others reported that APP processing in the endocytic pathway leads to the generation and release of both Ap 40 and

AP

42 into culture supernatant. To examine the intracellular pool of Ap 42 in APP mutants oO that lack the endocytic signal, CHO cells expressing an internalization-deficient APP polypeptide lacking 43 amino acids in the cytoplasmic tail were used (Perez et al. (1999) JBiol Chem 274:18851-6). Levels of cellular and secreted AP 42 and Ap 40 in cells expressing wild type APP and in cells expressing mutant APP were compared using ELISA. Results indicated that in the absence of the cytoplasmic tail, levels of Ap4o and

AP

42 secreted by cells expressing mutant APP were diminished compared to cells expressing wild type APP. In addition, in the absence of a cytoplasmic tail, cellular levels were reduced while cellular Ap 42 levels were not reduced.

Example 13 NSAlD treatment of T2576 transgenic mice NSAIDs were dissolved in an appropriate vehicle. Dimethyl sulfoxide (DMSO), ethanol, and ethyl acetate are some examples. The NSAID solution was mixed with Kool-Aid and administered orally using a medicine dropper. For three days, equal doses were administered every four hours, totaling 50 mg/kg/day. At two hours after the final doses were administered, animals were sacrificed, and SDS soluble Ap40 and Ap 42 were analyzed using ELISA.

Example 14 Treatment of animals with ibuprofen reduces A f2 levels To determine whether acute ibuprofen treatment of mice would reduce Ap 42 levels, three month-old Tg2576 mice expressing APP695 containing the 'Swedish" mutation (APP695NL) were used. Three month old mice have high levels of soluble AP in the brain but no AP deposition (see Hsiao et al. (1996) Science 274:99-102). Mice were given naproxen, ibuprofen, or meclofenamic acid as described in Example 13. Mice treated with ibuprofen (n=12) were compared with those untreated (n=l treated with naproxen or treated with meclofenamic acid Brain levels of SDS-soluble Ap 4 o and Ap 42 were measured using ELISA. Table 2 summarizes Ap40 and AP 42 levels Sdetermined for the control group and the naproxen, ibuprofen, and meclofenamic acidtreated groups. Treatment with ibuprofen or meclofenamic acid for three days resulted in cN 5 approximately 30% reduction in AP 42 levels in the brain, while no change was observed in Ap40 levels (see Figure 10). No reduction in Ap 42 levels was observed for naproxentreated mice. These data were consistent with the rapid onset of A3 42 reduction in cell oo culture studies and illustrated that cell culture experiments were able to predict in vivo efficacy. In addition, these data suggested that ibuprofen treatment could prevent amyloid pathology by decreasing Ap 42 /Ap40 ratio in the brain.

Table 2: Brain levels of A after acute dosing of Tg2576 mice (mean SD) Meclofenamic Control (n=l 1) Naproxen (n 7) Ibuprofen (n 12) acid (n 4) (finol/gm) 2603 314 2786 179 2620± 246 2932 289 AP42 1074 ±145 1182 93 734 302 679 343** %A342 29.3 ±2.9 29.8 ±1.6 21.5 7.7 18.6 8.7 p 0.05; p 0.01, Dunett's test Example 15 NSAIDs, NSAID derivatives, and NSAID analogues NSAIDs that are screened for the ability to reduce AP 42 levels include: FDAapproved NSAIDs, NSAIDs derivatives, and NSAID analogues most potent for reducing

AP

42 levels, newly synthesized derivatives and analogues of the most potent NSAIDs, and NSAIDS known to target pathways other than COX pathways. FDA-approved NSAIDs include ibuprofen, naproxen, dicolfenac, aspirin, indomethacin, fenoprofen, flurbiprofen, ketorolac. Derivatives of the most potent NSAIDs include aryl propionic acid derivatives such as ibuprofen and fenoprofen, and the anthranilic acid derivatives (also called amino carboxylic acid derivatives) such as the meclofenamic acid series and flufenamic acid.

(NSAIDs in both series share a similar core structure of either a diphenyl ketone or dephenyl ether.) Other derivatives or analogues that are screened for the ability to reduce

AP

42 levels include flufenamic acid, indomethacin, and meclofenamic acid derivatives and analogues (see Figure 11 and Kalgutkar et al. (2000) J ofMed Chem 43:2860-70).

Newly synthesized NSAID derivatives or analogues include novel biphenyl amines (Figure 12) and diphenyl ketones. Examples of NSAIDs that target additional pathways to COX include LOX inhibitors.

Once a set of NSAIDs, NSAID derivatives, or NSAID analogues having potent ability to reduce AD 42 levels is obtained, a pharmacophore search is performed to identify c-I 5 other NSAIDs structurally similar to those in the set. If a large number of candidates are identified, the structurally similar NSAIDs are subjected to a secondary structural screen using a computer-based molecular docking algorithm known as EUDOC. In the second 00 structural screen, crystal structures and COX-l/ COX-2 binding pockets are used to c-I identify a subset consisting of NSAIDs structurally similar to those that have potent ability to reduce AD 4 2 levels but do not bind COX-1 or COX-2. NSAIDs predicted to c-I bind to COX and those predicted to not bind to COX are used as controls.

NSAIDs, NAID derivatives, and NSAID analogues can be obtained commercially or they can be chemically synthesized. Novel NSAIDs, NSAID derivatives, or NSAID analogues with unknown effects on COX activity are tested using in vitro COX-1 and COX-2 assays to determine if there is an affect on COX activity.

Commercially available kits from Oxford biochemicals are used for COX inhibition assays.

Example 16 Determination of optimal screening interval for detecting selective reduction of 642 levels To determine the optimal treatment interval for examining selective reduction of A3 42 levels, CHO-APP695NL,I,his cell cultures were treated with the vehicle, or treated with ibuprofen or meclofenamic acid for six, twelve, or twenty-four hours. AD40 and AD3 42 levels in culture supematants were determined for each time points using ELISA.

Figure 13 is a bar graph demonstrating that selective reduction of AP 42 was detectable at six hours when cells were treated with meclofenamic acid. Similar results were observed for ibuprofen (data not shown).

'Example 17- Primary in vitro screening SIn a primary screen, the effects of NSAIDs on Ap42 secretion by a CHO cell line p^ that expressed APP (CHO-APP695NL,I,his) were examined. Duplicate cell cultures were Streated with a vehicle, 10 pM of NSAID, or 100 pM of NSAID.

C 5 To determine Ap4o and A3 42 levels, six-hour culture supemrnatants taken from cells grown in a single well of a twenty-four-well plate were used in end-specific AI3 4 o and

SAP

4 2 ELISAs (Suzuki, et al. (1994) Sci 264:336-1340). Ap 4 o and AP 42 levels of cultures Streated with NSAID were compared with those of cultures treated with the vehicle alone.

Concentrations of 100 pM Ibuprofen and 10 tM meclofenamic acid were used as positive controls. Results, in Table 3, indicated that some NSAIDs selectively reduce Ap 42 levels, but at the concentrations tested, many do not. NSAIDs were classified based on a change in AP3 levels observed in NSAID-treated versus vehicle treated cells.

Classification was made based on a 20% change because the data showed a 10% accuracy variance. When classification was made based on a 20 change, all NSAIDs screened, with the exception of two, were classified in the same category with repeated testing.

Two NSAIDs, shown in bold italic, gave results that altered their categorization upon rescreening; classification was resolved after a third test. These results confirmed the data described in Examples 8-10, as the NSAIDs that were shown to selectively lower A 42 initially also reduced Ap 42 in this screen. Of the newly synthesized biphenyl amines, meclofenamic, mefenamic, and flufenamic acid selectively reduced Ap 42 levels, while tolfenamic acid did not. NSAIDs that caused either selective reduction of Ap 42 levels or reduction in both Ap 4 o and Ap3 42 levels are subjected to a secondary screen.

Table 3. Effects of NSAJ.Ds on secreted Ap.

Type %Contro Contro %ontro Compound A/640 A.42 9A4l42 AO42 no effect on A4_ Sulindac Sulfide 10 pM Cox-1,2 97% 57% Flufenamic Acid 10 gM Cox-1,2 99% 64%/ Ibuprofen 100 ILM Cox-1,2 95% 74% 81% Ibuprofen 10 pM Cox-1,2 102% 80% 82% Flurbiprofen 100 gMl Cox-1,2 93% 70% Fenoprofen 100 tIM Cox-1,2 102% 60% 63% Mefenamic Acid 100 pM Cox-,2 116% 78% 72% Indomethacin 100 p Cox-1,2 101% 69% 68% 1AD42 4JAI340 NPPB 10pm Cox-12 81% 48% 66% Carprofen 100 pM Cox-1,2 58% 48% 86% Meclofenamic Acid 10 ttM Cox-1,2 39% 13% 37% LAI340 no effect on A 42 APHS 10pM Cox2'Coxl 50% 114% 178% Resveratrol 10 pm Cox -1 75% 107% 130% andfAD42 Meloxicam 10pM Cox-1,2 64% 122% 158% SC560 10 11 Cox-1>Cox -2 166% 227% Guaiazulene 100 pM Cox-1,2 70% 124%/6 156% AD42 NS398; 10pm Cox- 2> Cox-1 101% 146% 1320/ Ketorlolac 10 PM Cox-1,2 84% 131% 142% Benzydanine 100ptM COX-1,2 900/ 128% 132% A040 and/or IA42 Suprofen 100 ttM Cox-1,2 126% 129% 102% Indoprofen 100 pM Cox-1,2 116% 126%/6 107% Nabumetone 100 pM Cox4,2 157% 103% Piroxicam 100 pM Cox-1,2 142% 101% N Effect on AA Acetylsalicylic acid 100 pM Cox-1> Cox-2 93% 99% 104% Ketoprofen 100 IuM Cox-1,2 88% 107% 1170/ Fenbufen 100 piM Cox-1,2 100% 109% 107% Naproxen 100 pM Cox.1,2 107% 1120/ 104% Isoixicam 100 uM Cox-1,2 109% 112% 103% Tenoxicam 100 gM Cox-1,2 80% 92% 112% Tolfenamic Acd 100 pM Cox-1,2 84% 95% 1100/% Diclofenac; 100 tpm Cox-1,2 88% 87% 100% Etodolac 100 pLM Cox-1,2 85% 1090/ 120% Acemetacin 100 pM Cox-1,2 110%/6 101% 93% Niflumic Acid Cox-1 3 120% 107% Dapsone Anti -Bacterial 99% 80% 84% Sulindac Sulfone No-Cox 109% 97% 92% Nimesulide Cox-1,2 105% 116% 116% Suxibuzone Cox-1,2 82% 107% 129% Diflunisal Cox-1,2 90% 103% 112% Example 18 -Secondary and tertiary in vitro NSAID screening In a secondary screen, an extended dose-response study in which CHO cell cultures are treated with lnM to lmM of NSAID is performed. Dose response studies are used to estimate ICos values for maximum reduction of AP levels as well as to identify NSAIDs that have toxic effects. A secondary screen is performed for all FDA-approved NSAIDs that reduce AP 42 levels in cell cultures.

In a tertiary screen, AP3 production, sAPP production, and toxicity in a human H4 neuroglioma cell line that expressed APP are examined for all FDA-approved NSAJDs and novel NSAIDs that selectively reduce A3 42 levels. Three doses of each NSAID are tested. The first is a dose that is expected to cause maximum reduction of AP 42 levels.

The second dose is one that reduces AP 42 levels by 50% of the maximum value, while the third dose is one that reduces AP3 42 levels by 10-20% of the maximum value. Tertiary screens are performed on the most potent NSAIDs identified by secondary screens.

NSAID toxicity is measured using an MTS assay (see Example 1) and a lactate dehydrogenase (LDH) release assay (Promega Corp, Madison, WI).

Example 19 Acute single-dose studies to identifyV NSALDs having in vivo activity To determine whether NSAIDs that selectively reduce SDS-soluble AP 42 levels in cell culture studies also reduce brain AP 42 levels, in vivo studies using Tg2576 mice are performed.

Mice of either sex are used for acute studies. Each experimental group, however, is performed using mice of the same sex. Power calculations, based on past measurements of variability of Tg2576 brain AP levels, indicate that an of five mice per study group gives an 80% chance of detecting a difference of 20% or more at p<0.05.

These calculations are supported by experiments on wortmanin treated and A3 4 2 immunized Tg2576 mice, in which significant changes in A3 levels, even between groups of three to four mice, were noted (Haugabook et aL (2000) Faseb Although in most studies there are five mice per experimental group, in some instances, additional mice are used to account for loss due to death or illness. The use of additional mice also increases the power of ancillary studies such as those involving behavior, as sometimes, the number of mice needed to obtain a useful result is not known.

NSAIDs are prepared and administered to three-month-old Tg2576 mice as c-I described in Example 13. To avoid extensive testing of NSAIDs that are not active in vivo, high doses of NSAIDs are used initially. NSAIDs are administered every four to <1 eight hours; exact doses and dose schedules are determined from LD 5 o values, half-lives, N-i 5 and in vitro dose response studies. In general, a maximum dose that is non-toxic, typically ranging from 1/10 tol/5 of the LD 5 0 value of the NSAID, is used. If the LD 50 and other pharmacokinetic data of a given NSAID are unknown, their values are estimated using those of the nearest structural analogue.

c-i To monitor toxicity, weights of a mouse before and after the study are compared.

In addition, one mouse from each treatment group is subjected to a liver function test c-i (LFT) in which blood levels of two liver enzymes, SGOT and SGPT, are determined.

SGOT and SGPT are sensitive markers of liver toxicity. Furthermore, renal function, indicated by blood urea nitrogen (BUN) levels, is determined. Tests for liver and renal functions are performed by Anilitics (Gaithersburg, MD), a company that specializes in these tests. Those NSAIDs having toxic effects at high doses are not used in long-term studies unless their effectiveness and lack of toxicity at lower doses are established.

Following a three-day administration schedule, mice are sacrificed; Aj3 levels in plasma, brain, and CSF are determined; levels of NSAIDs in plasma are determined; and mice are examined for signs of toxicity. NSAIDs that selectively reduce SDS-soluble

AP

42 levels by more than 20-30% are examined in multiple dose response studies.

Example 20 Multiple-dose studies to identify doses useful for in vivo long-term animal and human studies NSAIDs that reduce A03 42 levels in vivo, at high doses, are administered to groups of three mice at high, medium, and low doses using the same dosing regimen described in Exampie 19. A high dose is the amount used in the single dose screen of Example 19, while medium and low doses are determined by inference from in vitro dose response studies described in Example 18. Those NSAfDs more potent than ibuprofen in vitro, those that have ICs0 values required for maximum reduction of AP 42 levels that are less than a mid jpiM value) are examined over a wide range of doses. For example, doses representing 1/50 to 1/10 of the IC 50 value are used in the multiple dose analysis.

NSAIDs having similar in vitro IC 50 values to ibuprofen are tested over a more limited

J

range. For example, doses representing 1/10 to 1/3 of the ICsO 0 value are used in the Smultiple dose analysis. Analyses of AP are performed as described for single dose studies. To identify plasma NSAID levels that correlate with A0 42 reduction in vivo, a plasma NSAID level is determined for each dose examined using the HPLC method C 5 described in reference 64 and adapted for each particular NSAID. Data pertaining to plasma NSAID levels in these multiple dose studies are used as reference values for both long-term animal studies where NSAIDs are administered in feed, as well as for 00 O subsequent human studies.

ci Example 21 Effects of NSAJDs on in vivo COX activity C- To determine if concentrations of NSAIDs used are sufficient to mediate antiinflammatory effects, novel NSAIDs are examined for their in vivo COX inhibitory activities and anti-inflammatory activities. For this study, the carrageneenan-induced footpad edema assay, described in Kalgutkar et al. (2000) JofMed Chem 43:2860-70, is performed on mice prior to sacrifice. For NSAIDs that do not reduce A0 42 levels, the assays are performed on mice treated with NSAIDs at levels equivalent to that administered in long-term studies.

Example 22- NSAIDs used in long-term preventative and therapeutic studies To determine whether the effects of NSAIDs on amyloid deposition in an animal model are attributable to direct inhibition of AP 4 2 accumulation, or reduction in inflammatory processes in the brain, or both, the following groups of NSAIDs are examined in long-term preventative and therapeutic tests. NSAIDs that selectively reduce A0 42 levels but lack anti-inflammatory properties, NSAIDs that selectively reduce Ap 42 levels and have anti-inflammatory properties, or NSAIDs that have no effect on Ap 42 levels but have anti-inflammatory properties are examined in both preventative and therapeutic studies. Ibuprofen is used to examine indirect inflammatory-mediated effects on AP deposition and direct effects caused by reduction of A342 levels, since it reduces

AP

42 levels and has anti-inflammatory properties. Celecoxib and naproxen, non-selective and selective Cox inhibitors, respectively, that do not cause reduction of Ap3 42 levels are used to examine A1342-independent inflammatory-mediated effects. NSAIDs examined in both preventative and therapeutic studies include those that exhibit one of these three (N properties: selectivity for Ap 4 2 reduction relative to COX inhibition, AP 42 reduction and p COX-2 selectivity, or solely increased potency for Ap 42 reduction in vivo.

Example 23 Long-term NSAID dosing for preventative and therapeutic trials Long-term dosing of mice is achieved through feed. Feed containing the desired concentration of NSAID can be obtained from commercial entities. Prior to long-term 00 preventative or therapeutic studies, successful administration of a chosen dose of NSAID Sthrough feed is verified using the following experiment. First, an NSAID concentration effective in reducing Ap 42 levels in acute studies, when administered by dropper, is C chosen. This concentration corresponds to the lowest dose that can generate a maximum reduction in Ap 42 levels. In the case of an NSAID that does not reduce Ap 42 levels, a concentration sufficient to cause anti-inflammatory effects is chosen. In the case of ibuprofen, the dose that reduces Ap 42 levels also is a dose that causes anti-inflammatory effects. Feed containing the chosen concentration of NSAID is used in a short-term trial to compare mice given NSAID by dropper to mice given NSAID incorporated into feed.

The reduction in Ap 42 levels as well as peak plasma levels of NSAID are determined for mice given NSAID by dropper and mice given NSAID through feed. If levels of Ap 42 reduction and peak plasma levels of NSAID in the two groups are comparable, then the chosen amount ofNSAID is achieved through feeding, and long-term preventative or therapeutic studies are performed. If levels of Ap42 reduction and peak plasma levels of NSAID in the two groups are not comparable, then the concentrations of NSAID in feeds are altered appropriately until reduction in Ap42 levels and peak plasma levels of NSAID in the two groups of mice are comparable.

SExample 24 Determination ofpeak plasma levels ofNSAIDs Techniques for determination ofibuprofen, fenoprofen, and meclofenamic acid Slevels in plasma are described in Canaparo et al. (2000) Biomedical Chromatography 14:219-26; and Koup et al. (1990) Biopharmaceutics Drug Disposition 11:1-15. In c 5 general, an internal standard is added to a plasma sample. The sample is acidified and subjected to organic solvent extraction. The organic phase is dried, dissolved in a small volume, and subjected to HPLC using a C18 column. Calibration and standardization are o00 carried out using untreated plasma spiked with NSAID for construction of a calibration 1 N curve.

NC- Example 25 CSF collection Mice are anesthetized with pentobarbital (30-50 mg/kg). An incision from the top of the skull to the mid-back is made and the musculature from the base of the skull to the first vertebrae is removed to expose the meninges overlying the cistema magna. The animal is placed on a narrow platform in an inverted fashion beneath a dissecting microscope. The tissue above the cistema magna is excised with care not to puncture the translucent meninges. The surrounding area is cleaned gently with the use of cotton swabs to remove any residual blood or other interstitial fluid. The dilated cisterna magna containing CSF is easily visible at this point. In addition to the cerebellum, brain stem, and spinal cord, an extensive vascular network also is visible. A micro needle and a polypropylene narrow bore pipette are aligned just above the meninges. With care not to disrupt any of the underlying vasculature, the micro needle is slowly inserted into the cistern. The CSF, which is under a positive pressure due to blood pressure, respiration, and positioning of the animal, begins to flow out of the needle entry site once the micro needle is removed. The micro needle then is pulled slowly backwards and the narrow bore pipette is used to collect the CSF as it exits the compartment. Once the needle is completely removed, the pipette is lowered into the puncture site and used to remove any remaining CSF. The primary collection usually takes less than 15 seconds for completion. The cistern will refill with several pL of CSF within two minutes. A second collection is performed to increase the net yield. At the end of the procedure, the emptied cistern is collapsed due to the removal of CSF. CSF is not collected past the first two minutes. The isolated CSF is transferred quickly into a pre-chilled polypropylene tube on 0 ice. Less than 5% of samples contain visible blood contamination.

Example 26 Biochemical, histochemical, behavioral, and toxicology evaluations of 5 long-term NSAID treatment When mice are sacrificed, one hemi-brain is processed for biochemical analyses and the other for immunohistochemical and histochemical analyses.

00 SAp 4 o, Ap 42 and total AP levels in mice brains are determined. Both SDS-soluble and Ci SDS-insoluble formic acid-soluble fractions are examined. ELISA, described in O 10 Kawarabayashi et al. (2001) J. Neur 21:372-381, and the BAN50 system, described in ci Suzuki et al. (1994) Sci 264: 1336-1340, are used. Both AP40 and Ap 42 polyclonal capture antibodies and end-specific polyclonal antibodies are available. Changes in levels of different Ap species due to NSAID treatments are examined by imunoprecipitationmass spectral analysis. AP levels in plasma and CSF are determined at the time of sacrifice.

To examine total plaque burden, brain sections are stained with anti-Ap antibodies. Antibodies to all Ap species as well as end specific Ap 40 and AP 42 antibodies are used. Cored plaques are detected by staining with thioflavin. Plaque number and amyloid burden are calculated as described in the Sigma ScanPro image analysis software (see Haugabook et al. (2000) Faseb Plaque types and extent of vascular and parenchymal amyloid depositions are examined.

Inflammation is examined by biochemical and histochemcial techniques.

Astrocytosis is examined using immunohistochemical staining and Western blotting of the SDS-extract for GFAP. Microglial activation is examined using staining techniques for anti-phophotyrosine as described in Lim et al. (2000) JNeurosci 20:5709-14.

Alternatively, microglia are immunostained using a pan MHC antibody or using SMI-312 GS lectin as described in Frautschy et al. (1998) Am JofPath 152:307-17. Inflammatory markers such as alACT and APOE are examined using Western blot analysis of the SDS-extract, while IL-1 and 1L-6 are examined using commercially available ELISA kits.

To examine neuronal loss and tau pathology, sections from brains are stained using haematoxylon and eosin. Sections are examined for overt pathological signs and n neuronal loss. Marked neuronal loss is quantitated using stereological counting. Tau Spathology is assessed using immunohistochemical staining by several anti-phosphorylated Stau antibodies.

For behavioral studies, a modified version of the Morris watermaze is used to detect learning and memory impairments related to amyloidosis in mice over-expressing APP (see Chen et al. (2000) Nature 408:975-979). Testing is conducted in fully Scounterbalanced, age-matched squads of mice (five to seven per group); trial blocks are 0 run at the same time each day, during the light cycle. Subjects run in a fixed order each i day with an inter-trial interval of approximately fifteen minutes. Trial spacing minimizes effects of hypothermia and fatigue that often are seen in older animals (see Rick et al.

(1996) J Gerontol A Biol Sci Med Sci 51:B253-60). The first day of testing consists of swimming to a visible platform. This assesses motivation, and visual and swimming ability. One trial is performed from a fixed starting position to each of four separate cued platform locations. In subsequent days, up to ten trials per day are performed using a learning criterion of three consecutive trials with less than twenty escape latency (see Chen et al. (2000) Nature 408:975-979). No probe trial is necessary since the only dependent variable measured is trials to reach criterion (TTC). Once an animal reaches criterion on one platform location, it is immediately switched to a new location. Testing is continued until five platform locations have been learned. Deficits in TTC are apparent in this paradigm primarily on the last two platform locations. These data are used with neuropathological data to assess the mice (see Chen et al. (2000) Nature 408:975-979).

Evaluation of neurological and sensorimotor skills is performed on the first day of testing, before the cued platform trial. A standard test battery is administered. This consists of ten minutes in an automated open field, examination of righting and grasping reflexes, latency to fall when suspended from a wire by the forepaws, and (d) rotorod performance. These tests screen basic functions such as strength, balance, and locomotor/exploratory behavior that can affect watermaze performance (Rick et al.

(1996) J Gerontol A Biol Sci Med Sci 51: B253-60; Murphy et al. (1995) Neur Learn Mem 64:181-6; Bickford et al. (1997) Neur Aging 18, 309-18; Cammisuli et al. (1997) Behav Brain Res 89:179-90; and Lewis et al. (2000) Nat Genet 25:402-5). In this way, effects of strength, balance, and locomotor/exploratory behavior on watermaze performance are accounted for.

As in acute studies, appropriate plasma markers are tested intermittently on a few NSAID treated mice to monitor liver and renal functions in both preventative and therapeutic trails. Weights of the mice are monitored bi-weekly, and complete blood counts are performed every two to three months. At the time of sacrifice, the G1 tract is examined for signs of ulceration using a dissecting microscope as described in Kalgutkar et al (2000) Jof Med Chem 43:2860-70.

Example 2 7- Determination of the effects of NSAIDs on Afl deposition long-term c-iP rvetative trial NSAIDs that selectively reduce Af3 42 levels in acute studies are examined in a c-i preventative trial to determine if they can prevent AP3 deposits. Six-month-old Tg2576 mice are used in preventative trials since AP deposit has not yet taken place. NSA]]) treatment of mice at this age corresponds to treating humans before signs of clinical disease occur.

Tg2576 mice are treated with experimentally optimized doses of NSAJID for three, six, and twelve months. Each treatment group consists of a minimum of twenty animals, five of which are examined at each of the three time points. The remaining five mice are included in case of illness or death during long-term dosing. Three to four mice are placed into a treatment group each month until groups of twenty animals are established.

At the time of sacrifice, tissues obtained for analysis are stored until all the mice within an experimental group have been sacrificed. Therefore, all samples from mice within one experimental group are examined simultaneously. For ibuprofen, naproxen, and control groups, twenty-seven mice are used per experimental group. The extra mice are treated for twelve months after which time behavioral patterns and additional pathologic parameters are examined.

The following NSAfl)s are used in preventative trials: ibuprofen which reduces

AP

42 levels, has anti-inflammatory activity, and has a short-half life; meclofenamic acid which is more potent at reducing A13 42 levels in vitro, and has anti-inflammatory activity; sulindac which reduces AP3 4 2 levels, has anti-inflammatory activity, and has an extendedhalf-life; naproxen which has no effect on AP 42 levels, but has anti-inflammatory activity, and COX-1I and COX-2 inhibitory activities; and celecoxib which is an anti-inflammatory COX-2 selective agent. In addition, other NSAIDs that reduce A342 levels but show selectivity for this effect over inhibitory effects on COX-1, COX-2, or both are included in this study. At three, six, and twelve months of treatment with NSAIDs, mice are <1 analyzed for behavioral alterations; then they are sacrificed and biochemical analyses are ci 5 performed as described in Example 26.

Example 28 Alteration ofAfl deposits by NSALDs long term therapeutic trial 00 5 To determine whether AP deposition, the effects of AP deposition, or both can be N, altered once AP3 has accumulated to a high level, NSAJDs that selectively reduce AP 42 levels in acute studies are examined in a therapeutic trial. Effects of treatment with c-,i NSAfDs that reduce AP 42 levels are compared to effects of treatment with NSAIDs that do not reduce AP 42 levels such as the non-selective COX inhibitor naproxen and the selective COX inhibitor celecoxib. Sixteen-month-old Tg2576 mice are treated with experimentally optimized doses of NSAIDs for three or six months. Sixteen-month-old mice have large amounts of A3 in the brain and therefore, are representative of human patients with clinical signs of AD. Amyloid deposition, behavior, and AD-like pathology are examined as described in Example 26. Fourteen mice per treatment group are used; at least five treated and five control mice are compared.

Example 29 Statistical Analysis Mann-Whitney and Dunnet's tests are used for comparisons between groups of treated and untreated mice. A number of correlative comparisons are made. Variables and outcomes used in statistical analysis for each study are the following. For in vitro screening experiments, variables include: A3 levels in media, NSAID concentrations, toxicity, and COX inhibitory activity; while primary outcomes include reduction in A3 42 levels and COX inhibitory activity. In acute single-dose studies, variables include: AP levels in brain, plasma, and CSF; NSAID concentrations in plasma and brain; and dose of NSAID. Primary outcomes of acute single-dose studies include reduction in brain AP 4 2 levels and plasma levels of NSAID, while secondary outcomes includes correlation of brain, CSF, and plasma AP levels. In long-term studies, variables include: AP levels in brain, plasma, and CSF; NSA]D concentrations in plasma (and brain, if possible); dose of O NSAID; amyloid burden; extent of inflammatory response; behavioral performance; and CI toxicity. Primary outcomes of long-term studies include effects on A3 levels in the brain, while secondary outcomes include evaluation of inflammatory response, behavior, toxicity, and correlative analyses.

cN Example 30 Clinical investigations in amyloid-reducing actions ofNSAIDs The most promising FDA-approved NSAIDs, determined by preclinical studies, 00 oo Sare examined for amyloid reducing actions in healthy subjects as well as subjects with 0 CN mild to moderate Alzheimer's disease These studies are performed in three-group O 10 parallel design; each group consists of twelve subjects. Subjects are treated with an NC- NSAID or a matching placebo several times a day, depending on the NSIAD, for fourteen days. Study NSAIDs are purchased and over-encapsulated by the San Diego VAMC Pharmacy service or by another compounding pharmacy. Placeboes are similarly encapsulated.

AD subjects are selected based on the following criteria. Subjects consist of men and women, ages 60-85, who are diagnosed with probable AD using the National Institute of Neurologic Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) test (McKhann et al. (1984) Neurology 34:939-944) or have mild to moderate dementia as determined by the Mini-Mental State Examination (MMSE, Mohs et al. (1996) Int Psychogeriatr 8:195-203). MMSE scores in the range of 15-25 indicate mild to moderate dementia. AD subjects have caregivers that can ensure compliance with medication regimens and with study visits and procedures.

Non-demented control subjects consist of men and women ages 60-80. Control subjects lack significant cognitive or functional complaints, or depression as determined by the Geriatric Depression Scale (GDS), and have MMSE scores in the range of 27-30.

Control subjects have the same general requirements as AD subjects with the exception that caregivers are not required. Both AD subjects and control subjects have good general health, subjects do not have serious or life-threatening comorbid conditions.

Subjects who have medically active major inflammatory comorbid condition(s) such as rheumatoid arthritis, or those who have peptic ulcer, gastro-intestinal bleeding, or intolerance of NSAIDs in the past are excluded from the study. Those who have contra-indications to lumbar puncture, such as severe lumbar spine degeneration, sepsis in the region of the lumbar spine, or a bleeding disorder are excluded from participation 0 in the study. In addition, subjects who currently or recently use medications such as NSAIDs, prednisone, or immunosuppressive medications such as cyclophosphamide that could interfere with the study are excluded. Recently is defined as within one month before undergoing the baseline visit (see next paragraph). Subjects undergoing acetyicholinsterase inhibitor (AChE-I) treatments for AD are not excluded if these subjects have been on stable doses for at least four weeks. Similarly, Al) subjects 0C) taking antioxidants such as vitamin E, vitamin C, or Gingko biloba are not excluded if they have been on stable doses for at least four weeks. Subjects who use NSAIDs or aspirin on a regular basis are excluded. If needed, analgesics such as paracetamnol (Tylenol) are provided during the fourteen-day study.

The study procedure consists of three in-clinic visits: an initial screening visit, a baseline visit, and a follow-up visit at fourteen days. During the screening visit, information needed to assess eligibility is obtained and MMSE is administered.

During the baseline visit, which takes place within two weeks of the screening visit, physical examinations and lumbar punctures are performed. Blood samples are drawn for laboratory tests such as APO-E genotyping and for plasma preparation (see Example 3 At this time, subjects or caregivers, in the case of AD subjects, are given a fourteen-day supply of study NSAID along with instructions about timing of doses and potential adverse effects. (For AD subjects, caregivers are required to accompany subjects; to each visit, and are responsible for monitoring and supervising administration of study NSATDs.) A calendar is provided on which times of medications and potential adverse symptoms are recorded.

The NSAII) treatment regimen consists of a fourteen-day treatment with NSALDs in the form of capsules taken two or three times a day with meals. A high and a low study dose of NSAID are used. For ibuprofen, study doses of 800 mg and 400 mg are used. A study dose of 800 mg consists of two 400 mg ibuprofen tablets, while a study dose of 400 mg consists of one 400 mg ibuprofen capsule and one placebo capsule. For sulindac, a study dose of 200 mg twice a day for a total of 400 mg per day is used. For meclofenamic acid, study doses of 100 mg and 400 mg per day are tested.

NSAfl~s are pre-packed into a day-by-day plastic medication dispenser.

During the follow-up visit, twelve or fourteen days after beginning treatment, vital signs and adverse side effects of study NSAIDs are assessed. Surplus NSAIDs are returned and counted. In addition, lumbar punctures are performed and blood samples are drawn for laboratory tests and for plasma preparations.

Visits during which lumbar punctures are performed and blood samples are drawn are scheduled for mornings with overnight fasting to avoid obtaining postprandial or hyperlipenic plasma samples, which can influence levels of A3 4 o and A13 42 Table 4 summarizes biological markers that are analyzed from plasma and CSF samples.

Table 4. Plasma and CSF biological markers 00 Assay Method Volume of CSF Volume of Plasma Protein, glucose, cells I ML A14o ELISA 100 IiL x2 (in 100 ,L duplicate) x2 A0 42 ELISA 100 piL x2 (in 100 jL duplicate) x2 A3 38 Mass Spectrometry 1 mL Isoprostanes Gas Chromatography/ 2 mL Mass Spectrometry M-CSF ELISA 50 ptL x2 (in duplicate) MCP-l ELISA 50 pL x2 (in duplicate) Tau, ELISA 50 gL x2 (in duplicate) P-taul8l 50 L x2 (in duplicate) 1_ Plasma levels of NSAIDs IPLC 1 L Example 31 Collection of plasma and CSF Plasma samples are prepared within 15-30 minutes after blood samples are drawn. Plasma samples are frozen at 70 °C until used. At least 6 mL of CSF and, whenever possible, 10-15 mL are drawn from each subject. Total cell, protein, and glucose estimations are performed. Samples are identified by a study ID number, and technicians who run ELISAs or other assays are blinded to the identity of the subjects or the treatment conditions.

Example 32 Specific assays ELISA is used to determine APQ 4 0 and AP 42 levels in CSF. Batches of samples are assayed simultaneously in duplicate on microplates according to established procedures In A 42 detection, two antibodies are used: a monoclonal antibody that recognizes an epitope within the first five amino acids of A3 is used for capture and (2) an end-specific monoclonal antibody that recognizes Ap ending at amino acid 42 and conjugated to horse radish peroxidase is used for detection. CSF levels of Ap 3 s are measured by mass spectroscopy as described in Example 6. CSF isoprostanes are C, 5 measured by gas-chromatography/negative chemical ionization mass spectroscopy using internal standards for calibration Montine et al. (1999) Neurology 52:562-565). CSF Slevels of MCSF, MCP-1, tau, and P-taul81 are determined. Commercially available ELISA kits are used for M-CSF (R&D Diagnostics) and MCP-1 (Pharmingen, San Diego) determinations. CSF tau and P-taul81 are determined using ELISA kits from Innogenetics, Inc., Plasma levels of specific NSAIDs are determined by HPLC methods CI described in published procedures (Canaparo et al. (2000) Biomed Chromatogrl4:219- 26).

Example 33 -Analysis of clinical data Reduction in AP 42 levels due to NSAIDs treatment is detected as decreases in Ap 42 levels in CSF and/or plasma. Therefore, subjects with AD or elderly control subjects who receive NSAID treatments show serial decreases in CSF and/or plasma AP 42 levels, while those who take a placebo will not show serial changes in CSF and/or plasma

A

4 2 levels.

To assess comparability between groups of subjects at baseline, demographic data age and gender), dementia severity (MMSE score), and APO-E e4 allele frequency are compared between placebo groups, and groups of subjects with AD or elderly controls that are treated with NSAIDs. Continuous variables are compared by ANOVA and frequencies of categorical variables such as gender and APO-E genotype are compared using Chi-squared or Fisher's exact test.

Changes in levels ofbiomarkers of interest between baseline samples to follow-up samples are calculated for each subject. Descriptive statistics are used to determine whether levels ofbiomarkers at baseline are normally distributed. If they are, then mean changes in each treatment group are compared with each placebo group using ANOVA.

If they are not normal, then data transformation is applied or non-parametric statistics are used to compare changes in biomarker levels between different groups of subjects.

To determine whether changes in A0 42 levels are accompanied by changes in A34o c-i and A5 3 s levels, CSF A3 levels in placebo groups are compared to that in treatment groups using ANOVA. Levels of biomarkers related to microglial function M-CSF and MCP-1), oxidative damage in the brain F-2 isoprostanes), and neuronal degeneration tau and P-taul 81) are compared before and after treatment as well as between groups treated with placebo or with NSAID. If levels of biological markers change after treatment with NSAID, the change is examined in relation to variables such 00 as age, gender, APO-E genotype, and plasma NSAID levels. Scatter-plots and appropriate statistical comparisons are used.

c-i Example 34 Statistical Power Calculations Published data indicate that CSF A0 4 2 levels remain stable on repeated lumbar punctures. The power to detect differences between subjects treated with NSAIDs and subjects treated with placeboes depends on magnitudes of changes in biomarker levels after treatment relative to baseline.

In published longitudinal data for CSF A1 42 levels in an AD patient group of 53 (see Andreasen et al. (1999) Arch Neurol 56:673-80), baseline CSF A03 42 level (mean SD) was 709 304 pg/mI and follow-up (10 months later) CSF A0 42 level was 701 309 pg/m.L. The correlation between the first and second CSF AP3 42 level was R 0.90. No published longitudinal CSF AP 42 data are available in healthy subjects. In two studies that included healthy subjects, the values for CSF AD3 42 levels were 1485 473 pg/ImL (see Galasko et al. (1998) Arch Neurol 55:937-45) and 1678 436 pg/mL (see Andreasen et al. (1999) Arch Neurol 56:673-80).

The power calculation uses the following assumptions: levels are stable over time as described in Andreasen et al. (1999) Arch Neurol 56:673-80 and variance of change is similar. The standard deviation is calculated as square root of correlation)*2*SDA2). A pre-post correlation of 0.8 for CSF A3 42 level is assumed.

If the change in pre-post mean CSF A3 levels is assumed to be approximately zero in the placebo group, then effect size depends on the mean level of A5 42 at baseline.

For example, for elderly controls, if the mean CSF AP 42 level is 1485 pg/mL (see Galasko et al. (19)Arch Neurol 55:937-45), then a 0.25 efetsize represents an increase or decrease of the mean by 371 pg/mL due to treatment.

For power calculations, the following are assumed: alpha 0.05, power 0.80, and two-group studies in which equal numbers of subjects exposed to placebo c-i 5 and treatment are used. For power calculations with an effect size of 0.25, a sample size of 11 in each of the two groups is required. With effect size of 0.2, an N of 16 is required in each group.

OC) Twelve subjects per group are used for each study allowing for detection of an effect size of 0.25 or higher. In pre-clinical studies, several NSAIIs (including ibuprofen and meclofenamic acid) reduced AP 42 levels in supernatants from cultured N- cells and in brain tissues of transgenic mice by over 25%. In long-term transgenic mouse studies using ibuprofen, reported in (Lim. et al. (2000) JNeurosci 20:5709-14), AP levels in the brain were about 38% lower when treated than untreated.

If the variance in CSF A03 42 levels between subjects or on repeated lumbar puncture is greater than in these projections, then sample size is re-assessed and group size is modified as needed. A similar set of calculations using published data on CSF Af3 42 levels in AD patients shows that groups of twelve patients are sufficient to detect a effect size.

Published longitudinal CSF data are available for CSF tau in AD. Sunderland et al. (1999) Biol Psychiatry 46:750-755 studied twenty-nine patients with AD having baseline CSF tau (mean SD) of 548 355 pg/mL, follow-up CSF tau at twelve months of 557 275 pg/niL, and an R-value of 0.85.

The decision to use twelve subjects per group is derived from AD3 data. Again, assuming CSF tau remains stable and unchanged on average in the absence of treatment, an effect size for a decrease in OSE tau by at least 33% relative to baseline is 183 pg/ImL of tau.

In a two-group study design with equal subject numbers receiving placebo and treatment, N 12 per group, and assuming a 0.05, then power is 73% for detecting an effect size of 33% or greater for tau.

With the exception of plasma AP levels that remained stable as indicated by preliminary ibuprofen studies, the degree of variation of longitudinal measurements of other biomarkers is not known. Ibuprofen studies in healthy elderly and subjects with Smild AD are performed first, then sample sizes are reassessed for all biomarkers Smeasured and necessary changes are incorporated in to other NSAID studies.

Ci 5 Example 35 Placebo-controlled study ofNSAIDs with A/3-lowering actions A double-blind randomized placebo-controlled study is performed using sixty AD subjects treated with a placebo, ibuprofen, or another FDA-approved NSAID with 00 Ap-reducing action at a well-tolerated dose for 48 weeks. Specific NSAIDs and doses 0 C- are selected based on results obtained in Example Subjects are 50-90 years of age and have diagnoses of probable AD as indicated Cl by the NINCDS-ADRDA test. Subjects have an MMSE range of 15-25, good general health, no life threatening or major medical illnesses; and caregivers who can supervise medication regimens and provide collateral information. Additional screening criteria are as described in Example Initially, subjects are assessed for.eligibility in a screening visit. MMSEs and physical examinations are performed. Blood samples are obtained for routine laboratory tests. Block randomization is used to assign patients to placebo or active treatment groups. Assignment is determined according to baseline MMSE scores so that dementia severity is similar in the placebo and active treatment groups.

During the baseline visit, scheduled within two weeks of the screening visit, vital signs are assessed, lumbar punctures are performed, and blood samples are drawn for APO-E genotyping and for plasma preparation (see Example 31). CSF levels of Ap 42 isoprostanes, tau, and P-tau as well as plasma levels of Ap 4 o and AP 42 are determined. In addition, cognition is assessed using the Alzheimer's Disease Assessment Scale cognitive component (ADAS-cog, see Galasko et al. (1997) Alzheimer Dis Assoc Disord 11; Suppl 2:S33-9) and MMSE, while functional ability is assessed using the Alzheimer's Disease Cooperative Study Activities of Daily Living Scale (ADCS-ADL) (see McKhann et al. (1984) Neurology 34:939-944). At this time, caregivers of subjects are given a twelve-week supply of study NSAID along with instructions on timing of doses and potential adverse effects.

At the 12-week visit, vital signs, stool guaiac, and adverse side effects are assessed. Unused NSAID is counted. At the 24-week visit, assessment procedures identical to those of the baseline visit are performed. A count of unused NSAIDs and an inquiry about adverse events are made. At the 36-week visit, assessment procedures identical to the 12-week visit are performed, while at the 48-week visit, assessment procedures identical to those of the baseline visit are performed. A count of unused NSAIDs and inquiry about adverse events are made. Table 5 summarizes the examinations performed at each visit in the study.

Table 5. Schedule of events 00 Baseline 12 week 24 week 36 week 48 week Check entry criteria, obtain X consent Screening blood tests X Demographics, medical X history Vital signs X X X X X X Rectal examination, stool X X X X X guaic MMSE X X X X ADAS-cog, ADCS ADL X X Dispense medications X X X Adverse events, pill count X X X X Lumbar puncture, plasma X X for Blood drawn for safety X X X laboratory tests I I I In addition, each subject/caregiver is interviewed by telephone at 4,8, 16, and weeks to inquire about continuation in the study, medication usage, and adverse events.

Example 36 Statistical analyses of placebo-controlled studies Statistical analyses involve the comparison of cognitive (ADAS-cog, MMSE), functional (ADCS-ADL), and biomarker data of subjects before and after treatment.

Subjects treated with NSAID for 48 weeks are expected to exhibit less cognitive and functional decline relative to subjects who are treated with placebo. NSAID treatments are expected to associate with improved biomarker indices in CSF and possibly in plasma.

Differences (As) between final and initial ADAS-cog and ADCS-ADL scores are referred to as primary outcome measures. Mean As for placebo and treatment groups are compared by ANOVA. To control for subjects who fail to complete the study, a Last Observation Carried Forward (LOCF) analysis is performed.

Changes in CSF levels of A3 42 tau, P-taul8l, F-2-isoprostanes, and plasma AP 42 and A0 4 0 are similarly analyzed as outcome measures using ANOVA, or a non-parametric test Kruskal-Wallis) if the data are not normal. Correlations between changes in biomarker measures and in clinical measures at 24 weeks are examined by scatter-plots and correlational analyses.

00 OTHER EMBODIMENTS iIt is to be understood that while the invention has been described in conjunction with the detailed description thereof, the foregoing description is intended to illustrate and not limit the scope of the invention, which is defined by the scope of the appended claims.

Other aspects, advantages, and modifications are within the scope of the following claims.

Claims (52)

1. A method for treating, or delaying the onset of, Alzheimer's disease, comprising: identifying a patient in need of the treatment or delay; and 0 administering to the patient an AP 42 -reducing effective amount of an O N Ap 42 -lowering agent which reduces the level of AP 42 secretion without 0 substantially affecting the level of Ap40 secretion from a human cell.

2. The method of Claim 1, wherein said Ap 42 -lowering agent is characterized by the ability to reduce the level of Ap 42 secretion, increase the level of Ap 3 8 secretion without substantially affecting the level of Ap 40 secretion in assays performed in Examples 8 and 12.

3. The method of Claim 1 or Claim 2, wherein said patient is diagnosed of mild Alzheimer's disease.

4. The method of any one of Claims 1 to 3, wherein said Ap 42 -lowering agent reduces the plasma concentration of Ap 42 in said patient. The method of any one of Claims 1 to 3, wherein said Ap 42 -lowering agent causes at least 50% reduction in Ap 42 /Ap 4 o ratio at about 200 pM in the assay of Example 9.

6. The method of any one of Claims 1 to 3, wherein said Ap 42 -lowering agent causes at least an about two-fold increase in Ap 38 /AP40 ratio at about pM in the assay of Example 12. 10/11/05

7. The method of any one of Claims 1 to 3, wherein at least one of the O z following is monitored before and/or after the administration of said AP 42 lowering agent: the plasma concentration of Ap 42 the plasma concentration of Ap40, the plasma concentration of A3 34 Ap 36 Ap 37 or Ap 39 the plasma concentration of Ap 3 8 the Ap 42 /Ap 4 o concentration ratio, (6) 00 Sthe concentration ratio between one or more of AP 34 A 3 6 Ap 3 7 Ap 38 and Ap 3 9 O N over Ap 40 and the total concentration of AP peptides.

8. The method of any one of Claims 1 to 7, wherein said Ap 42 -lowering agent is an NSAID, or a structural derivative or analogue thereof.

9. The method of any one of Claims 1 to 7, wherein said Ap 42 -lowering agent is flurbiprofen, or a structural derivative or analogue thereof. A method for treating, or delaying the onset of, Alzheimer's disease, comprising: identifying a patient in need of the treatment or delay; selecting an Ap 42 -lowering agent which reduces the level of Ap 42 secretion, increases the level of Ap 3 8 secretion without substantially affecting the level of Ap40 secretion from a human cell; and administering to the patient an Ap 42 -reducing effective amount of said Ap 42 -lowering agent.

11. The method of Claim 10, wherein said Ap 42 -lowering agent is characterized by the ability to reduce the level of Ap 42 secretion, increase the level of Ap 3 8 secretion without substantially affecting the level of Ap 40 secretion in assays performed in Examples 8 and 12. 10/11/05

12. The method of Claim 10 or Claim 11, wherein said patient is diagnosed O z of mild Alzheimer's disease.

13. The method of Claim 10 or Claim 11, wherein said Ap 42 -lowering agent reduces the plasma concentration of Ap 42 in said patient. 00 (14. The method of Claim 10 or Claim 11, wherein said Ap 42 -lowering agent causes at least 50% reduction in AP 42 /AP40 ratio at about 200 pM in the assay of Example 9. The method of Claim 10 or Claim 11, wherein said Ap4 2 -lowering agent causes at least an about two-fold increase in Ap38/AP40 ratio at about 75 pM in the assay of Example 12.

16. The method of Claim 10 or Claim 11, wherein at least one of the following is monitored before and/or after the administration of said Ap 42 lowering agent: the plasma concentration of Ap 42 the plasma concentration of Ap 4 o, the plasma concentration of AP3 4 Ap 36 Ap 37 or Ap39, the plasma concentration of Ap 38 the Ap 42 /Ap 40 concentration ratio, (6) the concentration ratio between one or more of AP3 4 As 3 6 A3 37 Ap 38 and Ap 39 over Ap 4 o, and the total concentration of AP peptides.

17. The method of any one of Claims 10 to 16, wherein said Ap 42 -lowering agent is an NSAID, or a structural derivative or analogue thereof.

18. The method of any one of Claims 12 to 17, wherein said Ap 42 -lowering agent is flurbiprofen, or a structural derivative or analogue thereof. 10/11/05 (i

19. A method for treating, or delaying the onset of, mild Alzheimer's disease, O0 z comprising: identifying a patient in need of the treatment or delay; and administering to the patient an Ap 42 -reducing effective amount of an Ap 42 -lowering agent, which is an NSAID or a structural derivative or analogue 00 thereof capable of causing a reduction in Ap 42 /Ap 40 ratio in the assay of 0 cN Example 8. The method of Claim 19, wherein said NSAID or NSAID structural derivative or analogue thereof lacks the ability to inhibit COX-1, COX-2, or both COX-1 and COX-2 activity.

21. The method of Claim 19 or Claim 20, wherein said A 42 -lowering agent is a flurbiprofen derivative which has one or more of the following alterations from flurbiprofen: the position of the propionic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, and the acetic acid substituent is altered.

22. The method of Claim 19 or Claim 20, wherein said Ap 42 -lowering agent is a fenoprofen or carprofen derivative which has one or more of the following alterations from fenoprofen or carprofen, respectively: the position of the propionic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, and the acetic acid substituent is altered. 10/11/05

23. The method of Claim 19 or Claim 20, wherein said Ap 42 -lowering agent O z is a meclofenamic acid or flufenamic acid derivative which has one or more of Sthe following alterations from fenoprofen or carprofen, respectively: the position of the carboxylic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the caraboxylic acid oo substituent are altered, the bond connecting the two phenyl rings is altered, 0 (N and the carboxylic acid substituent is altered. (N

24. The method of Claim 19 or Claim 20, wherein said Ap 42 -lowering agent is an indomethacin derivative in which the carboxylic acid group on indomethacin is altered to other substituents, and/or the substituent on the indole nitrogen is altered. The method of Claim 19 or Claim 20, wherein said AP 42 -lowering agent is a sulindac sulfide derivative which has one or more of the following alterations from sulindac sulfide: the methylthio derivative of sulindac sulfide is altered to other substituents, the acid group is altered to other substituents, and the fluoride is altered to other substituents.

26. The method of any one of Claims 19 to 25, wherein the plasma concentration of AP 42 in the patient is reduced.

27. The method of any one of Claims 19 to 25, wherein said Ap 42 -lowering agent causes at least a two-fold increase in As 38 /A340 ratio at about 75 pM in the assay of Example 12.

28. The method of any one of Claims 19 to 27, wherein at least one of the following is monitored before and/or after the administration of said Ap 42 10/11/05 lowering agent: the plasma concentration of Ap 42 the plasma O Sconcentration of Ap 40 the plasma concentration of AP3 4 Ap 36 Ap 37 or Ap 39 the plasma concentration of Ap 38 the Ap 42 /Ap40 concentration ratio, (6) the concentration ratio between one or more of Ap 34 Ap 36 Ap37, Ap38, and Ap 39 over Ap40, and the total concentration of AP peptides. 00

29. A method of reducing the level of Ap 42 in mammalian cells or tissues, 0comprising the steps of: administering to said cells or tissues an Ap 42 -reducing effective amount of an NSAID, or a structural derivative or analogue thereof, which reduces the level of Ap 42 in said cells or tissues. The method of Claim 29, wherein the level of Ap 38 is increased.

31. The method of Claim 29, wherein levels of one or more of A3 34 Ap 36 A3 37 and AP 39 are increased.

32. The method of Claim 29, wherein the level of Ap 4 o is unchanged.

33. The method of Claim 29, wherein said NSAID or structural derivative or analogue is an aryl propionic acid or a pharmaceutically acceptable salt or ester thereof.

34. The method of Claim 29, wherein said NSAID is selected from the group consisting of flufenamic acid, fenoprofen, sulindac sulfate, indomethacin, mefenamic acid, ibuprofen, and flurbiprofen, and pharmaceutically acceptable salts or esters thereof. 10/11/05 (i The method of Claim 29, wherein said NSAID, or structural derivative or O z analogue thereof, lacks the ability to inhibit COX-1, COX-2, or both COX-1 and COX-2 activity.

36. The method of Claim 29, wherein said AP 4 2 level in or secreted from said 00 cells or tissues is monitored. O In

37. A method for reducing the plasma Ap 4 2 concentration in a human, comprising: identifying a patient in need of the reduction; and administering to the patient an AP 42 -reducing effective amount of an AP 42 -lowering agent, which is an NSAID or a structural derivative or analogue thereof capable of causing a reduction in AI 42 /A3 4 o ratio in the assay of Example 8, wherein the plasma A3 42 concentration in said human is reduced.

38. The method of Claim 37, wherein said NSAID or NSAID structural derivative or analogue thereof lacks the ability to inhibit COX-1, COX-2, or both COX-1 and COX-2 activity.

39. The method of Claim 37 or Claim 38, wherein said A3 42 -lowering agent is a flurbiprofen derivative which has one or more of the following alterations from flurbiprofen: the position of the propionic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, and the acetic acid substituent is altered. The method of Claim 37 or Claim 38, wherein said Ap 42 -lowering agent is a fenoprofen or carprofen derivative which has one or more of the following 10/11/05 alterations from fenoprofen or carprofen, respectively: the position of the O z propionic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, and the acetic acid substituent is altered. 00 cI 41. The method of Claim 37 or Claim 38, wherein said Ap 42 -lowering agent is a meclofenamic acid or flufenamic acid derivative which has one or more of the following alterations from fenoprofen or carprofen, respectively: the position of the carboxylic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the caraboxylic acid substituent are altered, the bond connecting the two phenyl rings is altered, and the carboxylic acid substituent is altered.

42. The method of Claim 37 or Claim 38, wherein said Ap 42 -lowering agent is an indomethacin derivative in which the carboxylic acid group on indomethacin is altered to other substituents, and/or the substituent on the indole nitrogen is altered.

43. The method of Claim 37 or Claim 38, wherein said Ap 42 -lowering agent is a sulindac sulfide derivative which has one or more of the following alterations from sulindac sulfide: the methylthio derivative of sulindac sulfide is altered to other substituents, the acid group is altered to other substituents, and the fluoride is altered to other substituents.

44. The method of any one of Claims 37 to 43, wherein at least one of the following is monitored before and/or after the administration of said Ap 42 lowering agent: the plasma concentration of AP 42 the plasma 10/11/05 concentration of Ap 40 the plasma concentration of Ap 34 Ap 36 A 37 or Ap 3 9 O z the plasma concentration of AP 38 the Ap 42 /A3 4 o concentration ratio, (6) the concentration ratio between one or more of Ap 34 Ap 3 6 Ap 37 Ap 38 and Ap 39 over Ap4o, and the total concentration of AP peptides. 00 The method of any one of Claims 37 to 43, wherein said patient has not 0 N been diagnosed with Alzheimer's disease.

46. The method of any one of Claims 37 to 43, wherein said patient has a genetic predisposition to Alzheimer's disease.

47. A pharmaceutical composition comprising: an Ap 42 -reducing effective amount of an Ap 42 -lowering agent, which is an NSAID or a structural derivative or analogue thereof capable of causing a reduction in Ap 42 /A340 ratio in the assay of Example 8; an acetylcholinesterase inhibitor; and a pharmaceutically acceptable carrier.

48. The pharmaceutical composition of Claim 47, wherein said NSAID or NSAID structural derivative or analogue lacks the ability to inhibit COX-1, COX- 2, or both COX-1 and COX-2 activity.

49. The method of Claims 47 or Claim 48, wherein said NSAID or NSAID structural derivative or analogue causes at least 50% reduction in AP 42 /AP 40 ratio at about 200 pM in the assay of Example 9. 10/11/05 The method of Claim 47 or Claim 48, wherein said NSAID or NSAID structural derivative or analogue causes at least an about two-fold increase in Ap 3 8 /AP40 ratio at about 75 pM in the assay of Example 12.

51. The method of Claim 47 or Claim 48, wherein said Ap 42 -lowering agent oo is a flurbiprofen derivative which has one or more of the following alterations from flurbiprofen: the position of the propionic acid substituent on the phenyl Sring is altered, the position or type of substituents on the phenyl ring c1 opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, and the acetic acid substituent is altered.

52. The method of Claim 47 or Claim 48, wherein said Ap 42 -lowering agent is a fenoprofen or carprofen derivative which has one or more of the following alterations from fenoprofen or carprofen, respectively: the position of the propionic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, and the acetic acid substituent is altered.

53. The method of Claim 47 or Claim 48, wherein said Ap 42 -lowering agent is a meclofenamic acid or flufenamic acid derivative which has one or more of the following alterations from fenoprofen or carprofen, respectively: the position of the carboxylic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the caraboxylic acid substituent are altered, the bond connecting the two phenyl rings is altered, and the carboxylic acid substituent is altered.

54. The method of Claim 47 or Claim 48, wherein said Ap4 2 -lowering agent is an indomethacin derivative in which the carboxylic acid group on 10/11/05 indomethacin is altered to other substituents, and/or the substituent on the O Z indole nitrogen is altered. The method of Claim 47 or Claim 48, wherein said AP 42 -lowering agent is a sulindac sulfide derivative which has one or more of the following 00 alterations from sulindac sulfide: the methylthio derivative of sulindac sulfide Cl is altered to other substituents, the acid group is altered to other 8 substituents, and the fluoride is altered to other substituents.

56. A pharmaceutical composition comprising: an Ap 42 -reducing effective amount of an Ap 42 -lowering agent, which is NSAID or a structural derivative or analogue thereof that is capable of causing a reduction in AP 42 /Ap 4 o ratio in the assay of Example 8; an antioxidant and a pharmaceutically acceptable carrier.

57. The pharmaceutical composition of Claim 56, wherein said NSAID or NSAID structural derivative or analogue lacks the ability to inhibit COX-1, COX- 2, or both COX-1 and COX-2 activity, and wherein said antioxidant is vitamin E.

58. The method of Claims 56 or Claim 57, wherein said NSAID or NSAID structural derivative or analogue causes at least 50% reduction in AP 42 /Ap 4 o ratio at about 200 pM in the assay of Example 9.

59. The method of Claim 56 or Claim 57, wherein said NSAID or NSAID structural derivative or analogue causes at least an about two-fold increase in Ap 38 /Ap 40 ratio at about 75 pM in the assay of Example 12. 10/11/05 The method of Claim 56 or Claim 57, wherein said AP 42 -lowering agent is a flurbiprofen derivative which has one or more of the following alterations from flurbiprofen: the position of the propionic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, and the acetic acid substituent is altered.

61. The method of Claim 56 or Claim 57, wherein said Ap 42 -lowering agent is a fenoprofen or carprofen derivative which has one or more of the following alterations from fenoprofen or carprofen, respectively: the position of the propionic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the propionic acid substituent is altered, the bond connecting the two phenyl rings is altered, and the acetic acid substituent is altered.

62. The method of Claim 56 or Claim 57, wherein said Ap 42 -lowering agent is a meclofenamic acid or flufenamic acid derivative which has one or more of the following alterations from fenoprofen or carprofen, respectively: the position of the carboxylic acid substituent on the phenyl ring is altered, the position or type of substituents on the phenyl ring opposite the caraboxylic acid substituent are altered, the bond connecting the two phenyl rings is altered, and the carboxylic acid substituent is altered.

63. The method of Claim 56 or Claim 57, wherein said Ap 42 -lowering agent is an indomethacin derivative in which the carboxylic acid group on indomethacin is altered to other substituents, and/or the substituent on the indole nitrogen is altered. 10/11/05

64. The method of Claim 56 or Claim 57, wherein said Ap 42 -lowering agent O z is a sulindac sulfide derivative which has one or more of the following alterations from sulindac sulfide: the methylthio derivative of sulindac sulfide is altered to other substituents, the acid group is altered to other substituents, and the fluoride is altered to other substituents. oo A method for treating, or delaying the onset of, Alzheimer's disease In O substantially as hereinbefore described with reference to the examples and the c accompanying drawings.

66. A method of reducing the level of Ap 42 in mammalian ceils or tissues substantially as hereinbefore described with reference to the examples and the accompanying drawings. 66. A method for reducing the plasma A3 42 concentration in a human substantially as hereinbefore described with reference to the examples and the accompanying drawings.

67. A pharmaceutical composition substantially as hereinbefore described with reference to the examples and the accompanying drawings. Dated this 10 t h day of November 2005 The Regents of the University of California and Mayo Foundation for Medical Education and Research Patent Attorneys for the Applicant PETER MAXWELL ASSOCIATES 10/11/05